Are you-up-to date with regard to scribe requirements? Please review the following information if you utilize the services of a live or virtual scribe. These required components must be specified in your work flow and documentation when working with a scribe.
Documentation of scribed services must indicate BOTH who performed the service and who recorded the service.
The physician’s note should indicate:
- Affirmation that you personally per-formed the services documented.
- Confirmation that you reviewed and confirmed the accuracy of the information in the medical record.
- Your electronic signature.
Sample practitioner attestation:
"The documentation recorded by the scribe accurately reflects the service I personally performed and the decisions made by me." Signature/Date/Time. This can be recorded as a dot phrase.
The scribe’s note should include:
- The name, title, and signature of the scribe.
- The name of the practitioner providing the service.
Sample scribe attestation:
"Entered by ________, acting as scribe for Dr./PA/NP ________." Signature/Date/Time
According to The Joint Commission, a scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) at the direction of a physician or licensed independent practitioner (LIP). The scribe does not and may not act independently but documents the physician’s or LIP’s dictation and/or activities. The scribe must have a job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities.