August 10, 2017
In my office, we use a PA as a scribe for new patient office visits for our doctors. We have an electronic medical record and the scribe signs in under her own name when she begins notating for the doctor. What is the correct way to notate in the medical record that the PA is only acting as a scribe and not performing the service personally?
Good question. In order to clearly indicate what was performed, the documentation must identify who rendered the service and that the PA was acting solely as a scribe and did not perform any of the services. Remember, a scribe does not ask the patient questions or perform any examination of the patient. Both parties need to sign the medical record (electronically will suffice) and attest to the situation. Noridian, the Jurisdiction E local Medicare contractor, gives the following acceptable attestation example:
“I, _____________, am scribing for, and in the presence of, Dr. ____________.” for the scribe; and
“I, Dr. __________, personally performed the services described in this documentation, as scribed by ________________ in my presence, and it is both accurate and complete.” for the physician.
Some payors only require the physician to sign the note as an attestation and not make a separate statement (as in the Noridian example above). You may want to check with your payors to see if they have specific verbiage that they look for to support the use of a scribe.
*This response is based on the best information available as of 08/10/17.