How Should 'Scribes' Be Used? Scribe Rules, Explained

Carolyn Buppert, MSN, JD

Disclosures

December 05, 2017

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Question

How Should 'Scribes' Be Used?

Response from arolyn Buppert, MSN, JD
Healthcare attorney

Using a Scribe

A nurse practitioner asks the following question about scribes. "My employer has offered us scribes. What do I need to know, to be compliant with Medicare and to avoid malpractice, if I use a scribe for my documentation?"

The short answer is: Use the scribe as a stenographer. The scribe takes your dictation or clicks the boxes that you tell the scribe to click on an electronic record. The scribe does not make any medical or nursing decisions and does not perform any part of the physical examination or obtain the history of present illness.

Here are the details. Read the scribe's documentation and change anything that is inaccurate. Sign the documentation and write, "I, [your name], personally performed the services described in this documentation, as scribed by [scribe's name] in my presence, and it is both accurate and complete." Medicare does not require the scribe to sign the notes. Your practice or facility may have a policy on whether the scribe needs to sign the note. The Joint Commission does want the scribe to sign each note.

If you are working in a hospital, it's important to know where The Joint Commission stands on scribes. Surveyors expect to see:

  • A job description for the scribe that recognizes the unlicensed status and defines the qualifications of the scribe and the scribe's responsibilities

  • Orientation and training for the scribe, with content to include HIPAA rules, state confidentiality rules, and patient rights standards

  • Competency assessment and performance evaluations

  • Written by the scribe on each note: "Scribed for [provider name] by [name of scribe and title] on [date] at [time]."

  • Signature of credentialed, licensed provider, along with date and time of entry[1]

What Scribes Can and Cannot Do

The scribe (or any office staff member) may obtain and document the patient's past, family, and social history (PFSH) and the review of systems (ROS).[2] This information also may be collected on a form, filled out by the patient, and then transferred to the record. The nurse practitioner, physician assistant, or physician need not repeat the PSFH or ROS but must confirm the information recorded by the scribe or provided by the patient on a form. The nurse practitioner, physician assistant, or physician must obtain the chief complaint, history of present illness, examination, and medical decision-making.[2] The scribe can write it down or fill in the medical record boxes.

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