MAR 02, 2017
5 Tips for Use of Medical Scribes
Many physicians use medical scribe services to reduce documentation overload and support work flow. Medicare does not have requirements for or a definition of these services, but the Joint Commission defines a scribe as “an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician.”
Follow these guidelines when using medical scribe services:
- Identify who recorded the service. Example: "I, ___________, am scribing for, and in the presence of, Dr. _______."
- Have the scribe sign and date this attestation.
- Identify who performed service.
- Indicate physician approval ofthe record’s accuracy of both his/her words and actions during that visit, after first assuring any correction or addition, if necessary.
- Example: "I, Dr. __________, personally performed the services described in this documentation, as scribed by __________ in my presence, and it is both accurate and complete."
- Have physician or practitioner sign and date this attestation.
Scribes can document the physician’s dictation and/or activities, but cannot act independently. Scribes may also assist in EHR navigation, medical record coding and locating information such as test and lab results. Learn more about requirements for scribes in Ophthalmic Coding: Learn to Code the Essentials.