Scribes

Objective

To apprise CUIMC clinicians of the regulation and documentation requirements when using a scribe to document their patient visits.

Policy

When an ancillary or other staff member is documenting services performed by the physician, the ancillary or staff member is acting as a scribe.  Nurse Practitioners or Physician Assistants may not act as scribes if they provide any portion of the service.

The scribe is present during the encounter and records in real time the actions and words of the physician as they occur. Scribes may not interject their own observations or impressions into the medical record. Physicians may rely on the review of systems (ROS) and past, family social history obtained and recorded by ancillary personnel.

The physician is responsible for all documentation and must verify that the scribe’s note accurately reflects the service provided.

Scribe Documentation Requirements

The personnel scribing for the physician should sign as the scribe and the physician should sign the note as well as referencing the work of the scribe but stating that he/she performed the service.
A scribed note must include a personal note from the scribe that he/she was acting as a scribe on behalf of a physician.

Scribe Example

I__________(scribe name) am acting as a scribe for Dr. ________________on _________(date).

Scribes Signature_____________

Provider Documentation Requirements

A signed attestation by the provider indicating that the note accurately reflects the provider’s personal service and that it was scribed on his/her behalf.

Provider Example

I Dr._____, obtained the HPI, performed the exam and formulated the decision making. I have edited the note which was scribed for me by _____________(scribe name).

Provider Signature______________

REFERNCES:

Faculty Practice Organization Policy Number – PC 1.21 

Office for Billing Compliance
Policy#: 10029
Original Date of Issue: 1996
Revised: 3/22/2023
Reviewed: 3/1/2024