Defining the scribe?s function as a living recorder, documenting in real time the actions and words of the qualified provider as they are completed.Certification and licensure requirements.Responsibilities and clear scope of practice.The policy clarifies CMS documentation signature requirements.Scribes may document only the words and activities as they are performed by the qualified provider during a patient encounter.Enacting a policy to define a scribe?s role, to include a documented job description.Policies and procedures identify responsibilities and outline requirements for scribes, while also setting the tone and defining expectations and accountability.Ī quick checklist for compliant use of medical scribes: Scribe documentation must be managed and maintained with the same quality assurance and compliance expectations of other patient care documentation. One must closely monitor use of scribes for accuracy and adherence to applicable guidelines, through the development of policies and procedures, training, and overall management. ![]() It is crucial that scribe programs are included in the organization?s overall compliance program. ![]() ![]() Scribes are not permitted to make independent decisions or translations, beyond what is directed by the provider, while capturing or entering information into the health record or Electronic Health Record.Ī Medical Scribe is essentially a personal assistant to the physician performing documentation in the EHR, gathering information for the patient’s visit, and partnering with the physician to deliver the pinnacle of efficient patient care. Scribes aren’t licensed coders, but they should receive training in clinical terminology, basic CPT codes, EHR and of course HIPAA guidelines.Ī scribe?s core responsibility is to capture accurate and detailed documentation (handwritten or electronic) of the encounter, in a timely manner. A medical scribe is an unlicensed individual hired to enter information into the electronic health record (EHR) or chart at the direction of a physician or licensed independent practitioner.
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