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  • Who Documents the Order for Testing?

    Can a scribe document the testing service that the physician orders under their log in? The documentation states, "written by (scribe’s name) acting as a scribe for (physician’s name)." Or is the physician required to login and order the test?

    A scribe enters data on behalf of a physician. If the physician gives an order for a test, then the scribe may enter it into the electronic health records (EHR). The physician must electronically sign the order and/or medical record.

    From the Fundamentals of Ophthalmic Coding:

    “Scribe” situations are those in which staff are used to document work performed by the physician in either an office or a facility setting.

    In E/M services, a scribe does not act independently but simply documents a physician’s dictation and/or activities during the visit. The physician who receives payment for the services is expected to be the person delivering the services and creating the record, which is simply written down by another person.