Forum - Questions & Answers

Jun 5th, 2009 - pberrett

Scribes

Anyone know the regs on this?? I can't seem to find any regulations in Medicare?
How this service works, what credentials are needed to perform this service, What is the protocol?

Jun 5th, 2009 -

Hire anyone!

A scribe in an office can be anyone-no one is going to regulate that- the physician is responsible for the content of the note. A scribe never touches a patient but you should give them OSHA training and hep B vaccine and influenza shots.

Jun 5th, 2009 - nmaguire   2,606 

scribe

If a nurse or mid-level provider (PA, NP, CNS) acts as a scribe for the physician, the individual writing the note (or history or discharge summary, or any entry in the record) should note "written by xxxx, acting as scribe for Dr. yyy." Then, Dr. yyyy should co-sign, indicating that the note accurately reflects work and decisions made by him/her.
It is acceptable for a physician to use a scribe, but current documentation guidelines must be followed. The physician is ultimately accountable for the documentation, and should sign and note after the scribe's entry the affirmation above, that the note accurately reflects work done by the physician.
Record entries made by a "scribe" should be made upon dictation by the physician, and should document clearly the level of service provided at that encounter. This requirement is no different from any other encounter documentation requirement. Medicare pays for medically necessary and reasonable services, and expects the person receiving payment to be the one delivering the services and creating the record. There is no "incident to" billing in the hospital setting (in-patient or out-patient). Thus, the scribe should be merely that, a person who writes what the physician dictates and does. This individual should not act independently, and there is no payment for this activity.



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