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Do You Use the Services of a Scribe?

April 15, 2018

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.