Skip to Main Content
 
 
 
Web Content Viewer

Policy Education Topics

Web Content Viewer
Web Content Viewer

Scribing Medical Record Documentation

National Government Services recognizes an increasing trend in providers’ use of scribes as assistants in medical record documentation. In these situations, a provider utilizes the services of staff to document work performed by the provider, in either an office or a facility setting.

In documenting any patient encounter, the scribe neither acts independently nor functions as a clinician, but simply records the provider’s dictated notes during the visit. The provider who receives the payment for the service is expected to deliver the service and is responsible for the medical record; the scribe may simply enter information on the provider’s behalf, all of which must be corroborated (i.e., approved) by the provider.

Some electronic medical record programs allow the provider to amend the scribe’s entry before the provider signs and enters the note into the record; this is permissible. When a scribe enters on a paper medical record and correction is needed, the provider must add and sign an addendum to the scribe’s note, rather than cross out or alter what the scribe has written.

During a patient encounter, the scribe may additionally perform standard medical assistant functions, as long as the scribe remains available to the provider and free to document the provider’s verbal observations in real time. The act of scribing is intended to take place as the provider dictates his/her notes regarding the patient’s history, exam and plan of care. The scribe is not permitted to record any independent notes, but only those specifically dictated by the provider.

Physicians using the services of a "scribe" must adhere to the following:

  • Physician cosigns the note indicating the note is an accurate record of both his/her words and actions during that visit.
  • Record entry notes the name of the person "acting as a scribe for Dr. _____"
  • Documentation supports both the medical necessity of the level of service billed and the level of the key components required of the service. See Related Content for E&M guidelines.

In the office setting, a staff member may independently record the past, family and social history (PFSH) and the review of systems (ROS), and may act as the provider's scribe, by simply documenting the provider's words and activities during the visit. The provider may count that work toward the final level of service billed. However, the provider must document that he/she reviewed this information. However, in the same setting, an NPP accomplishing the entire visit should report those services under his or her own PTAN, unless "incident to" guidelines have been met.Only when the "incident to" guidelines have been met, should the physician's name and NPI be used to bill Medicare for that service.

In a facility setting (hospital or skilled nursing home), when a NPP independently performs and documents an E&M service, the NPP is not functioning as a scribe, even if the documentation is later reviewed and/or co-signed by a physician. The service does not qualify as a split/shared visit, since the NPP performed the full service. “Incident to” concepts do not apply in the inpatient setting, and work performed exclusively by a NPP should be billed under the NPP's name and NPI.

Scribe usage may be appropriate and included in a Medicare provider's practice, when properly administered and documented. The Medicare provider must assume full responsibility for the performance, documentation, coding and billing of any scribed service.

Related Content

 

Scribing Medical Record Documentation
Web Content Viewer
Web Content Viewer
Complementary Content