Scribe FAQ

A scribe works side by side with the practitioner as a documentation and throughput assistant. The scribe can accompany the practitioner into the exam room and document the practitioner-patient encounter as it is verbalized by the practitioner and patient. The practitioner may also dictate the patient encounter to the scribe. Additionally, the scribe can gather data for the physician including (but not limited to) nursing notes, prior records, lab and radiology results, facilitating the efficiency of the patient's visit. With the exception of obtaining PFSH and ROS, a scribe cannot act independently, but simply documents the practitioner's conversation and/or activities and relays information and cues back to the physician during the visit.

While not specifically addressed in CMS policy, many Medicare Administrative Contractors (MACs) require documentation by a scribe to include their name and who they are scribing for, i.e.  "Entered by_____________________, acting as scribe for Dr./PA/NP___________________________." 

The practitioner should review the scribe’s documentation and attach a signature to affirm the note adequately documents the care provided.

CMS addresses the use of scribes in the Signature Requirements section of the Medicare Program Integrity Manual that was revised via Transmittal 713 in May of 2017.

“Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note.”

CMS also commented on scribes in the MLN Fact Sheet that accompanied the release of Transmittal 713.

“What if I use a scribe when documenting medical record entries?

Regardless of who writes a medical record entry, you must sign the entry to authenticate it adequately documents the care you provided or ordered. It is unnecessary to document who transcribed the entry.”

Historically, all the MACs addressed the use of scribes via their websites.  Most have revised or updated their scribe policies to be consistent with the above referenced CMS policy.  Below are what is currently posted from each of the MACs related to scribes. 

Noridian Healthcare Solutions - Jurisdiction E and F

“To reduce the amount of documentation overload, many physicians are looking to Medical Scribe services.

Per CMS Change Request (CR)10076, Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician's/non-physician practitioner's (NPP's) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.”

Wisconsin Physicians Service - Jurisdiction 5 and 8

After the release of Transmittal 713 WPS replaced their scribe policy with this FAQ.

1. "Could the scribe also document the attestation and have the physician sign.
2. In a scribe situation, there is no need for an attestation. The physician’s signature validates the information contained in the medical record. CMS changed the information on scribes in Change Request 10076. We removed other information we had published on scribes."

A more recent review of their website shows that they do not specifically address scribes but do link to the MLN Fact Sheet mentioned above. In a meeting minutes from the 2/22/18 Provider Outreach and Education Advisory Group meeting they do state,

“In a scribe situation, there is no need for an attestation. The physician’s signature validates the information contained in the medical record.”    

National Government Services - Jurisdiction 6

NGS addressed scribes with a policy document and a separate FAQ.

"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.

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:

1. Physician cosigns the note indicating the note is an accurate record of both his/her words and actions during that visit.
2. Record entry notes the name of the person "acting as a scribe for Dr. _____"

Novitas Solutions - Jurisdiction H and L

Novitas added the revised signature requirements to their existing policy, which it seems to contain conflicting information.

"Scribed services are those in which the physician utilizes the services of ancillary personnel to document/record the work performed by that physician, in either an office, or a facility setting. The scribe does not act independently, but simply documents the physician’s dictation and/or activities during the visit in the patient’s chart or Electronic Health Record (EHR).

Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.

Documentation of a scribed service must clearly indicate:

Who performed the service.

Signed and dated by the treating physician or non-physician practitioner (NPP) affirming the note adequately documents the care provided

I agree with the above documentation' or 'I agree the documentation is accurate and complete' *

If an NPP is utilized and acting as a scribe for the physician, the medical record should clearly indicate the NPP is acting as a scribe. This applies to all scribed encounters, whether scribing was performed by licensed clinical staff or other ancillary staff.

Examples*

Billing provider’s note: ‘_______________, acted as scribe for this encounter on _________”,

Billing provider’s note: “_____________(scribes name) scribing for ___________(physician/non physician provider name)

It is recommended to include the identity of the scribe within the medical record documentation as the recorder of the service performed. It is expected that the use of a scribe to be clinically appropriate for each situation and in accordance with applicable state and federal laws governing the relevant professional practice, hospital bylaws and any other relevant regulations." 

Palmetto GBA - Jurisdiction J and M

"A scribe can be a non-physician practitioner (NPP), nurse or other appropriate personnel designated by the physician/NPP to document or dictate on their behalf. A scribe does not have to be an employee of the physician/NPP. 

Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), the Centers for Medicare & Medicaid Services (CMS) does not require the scribe to sign/date the documentation. The treating physician’s/NPP’s signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided.

The Medicare Administrative Contractor (MAC) is only required to look for the signature (and date) of the treating physician/NPP on the note. Services shall not be denied for items or services because a scribe has not signed/dated a note."

CGS Administrators - Jurisdiction 15

The scribe is functioning as a "living recorder," documenting in real time the actions and words of the physician as they are done. If this is done in any other way, it is inappropriate. The real time transcription must be clearly documented by both the scribe and the physician. Failure to comply with these instructions may result in denial of claims. 

Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician's/non-physician practitioner's (NPP's) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/non-physician practitioner on the note. Reviewers shall not deny claims for items or services because a scribe has not signed/dated a note.

Documentation must identify who performed the service.

The physician/practitioner MUST sign and date all documentation timely.

This revision is ONLY regarding the scribe signature requirements, it does not indicate that you do not need to note when a scribe is used."

First Coast Service Options - Jurisdiction N

After the release of Transmittal 713 FCS replaced their scribe policy with:

"If a nurse or non-physician practitioner (PA, NP) acts as a scribe for the physician, the individual writing the note (or history or discharge summary, or any entry in the record) should note “written by xxxx, acting as scribe for Dr. yyyy.” Then, Dr. yyyy should co-sign, indicating that the note accurately reflects work and decisions made by him/her."

A more recent review of their website shows that they do not specifically address scribes.

The scribe is only recording the words and descriptions of the service performed and verbalized by the practitioner. Since scribes have no patient care responsibilities, there are no training or background requirements regarding who can act as a scribe.

Although there are no documented restrictions as to who can act as a scribe, payers have expressed concern about residents or NPPs acting as scribes because of their ability to independently evaluate the patient separate from the physician and the difficulty in separating documentation performed when acting as a scribe versus documentation of services performed as a healthcare provider.

Medical students frequently act as scribes. The documentation should be clear that the medical student is functioning as a "living recorder" documenting the words of the practitioner.

Historically, TJC had a rather detailed policy document pertaining to scribes.  After the release of Transmittal 713 TJC replaced their scribe policy with: “The use of scribes in healthcare settings is currently under review. Any updates or changes will be published in future editions of the Perspectives Newsletters and/or via the Joint Commission Online newsletter.”

A more recent review of their website shows that they do not have a policy that specifically addresses scribes.