The following article is taken directly from a publication by the Connecticut Medicare contractor, National Government Services.
Physicians may on occasion utilize the services of scribes to assist with documentation during a clinical encounter between the physician and patient. 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.
The physician is ultimately responsible for all documentation and must verify that the scribe’s note accurately reflect the service provided.
The Scribe's note should also include
• The name of the scribe and a legible signature
• The name of the physician providing the service
• The date the service was provided
• The name of the patient for whom the service was provided
The physician’s note should indicate:
• Affirmation of that physician’s presence during the time encounter was recorded
• Verification that he/she reviewed the information
• Verification of the accuracy of the information
• Any additional information needed
In a teaching facility setting attending physicians may employ scribes, but residents or fellows may not, since the creation of the medical record is inherent to the training programs (paid for under Graduate Medical Education [GME] program) and to the medical care delivered by these residents.
Signature requirements detailed in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1, (1 MB) as well as the specific documentation requirements for any service provided must be followed. Source: Important Information from National Government Services Regarding Documentation Requirements when Scribes are Utilized ngslistserve.com September 15, 2010