You probably prefer to spend less time documenting a patient visit and more time actually interacting with the patient, right? If so, you may want to consider hiring a scribe.
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Explore This IssueApril 2011
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The Role of a Scribe
A scribe is a person who is professionally trained in medical documentation. A scribe would accompany you in the examination room to accurately document the details of the visit. All communication between the patient and physician, the examination, procedures, and laboratory and radiology results or orders would be accurately documented.
Scribes are proficient in coding and documentation guidelines, which mean the recorded notes would substantiate the medical necessity of that visit.
There are benefits for both physicians and patients to having a scribe on staff. Physicians benefit from dedicated time to focus on patient needs and other necessary areas of the practice instead of paperwork and potentially save time and money by decreasing overpayments and penalties.
What a Scribe Can and Can’t Do
Scribes must accurately and completely document patient’s medical charts, and each chart must be signed and dated by the scribe and physician. A scribe can submit labs and radiology orders and can alert the physician when results from a test that was performed come back.
There are also some things that scribes are not allowed to do. Scribes cannot omit or add any information to the physician’s clinical examination. No information can be given directly to scribes by a patient, nor can scribes insert their own medical opinion into the record concerning the patient’s visit.
More and more carriers are accepting scribe documentations. Each carrier has specific rules on the utilization of scribes. A Cigna Medicare Part B bulletin from December 2004 states that whomever writes the note is acting as a scribe for the physician and the physician must co-sign this statement. Highmark BlueCross BlueShield states that the notes must clearly state who performs the service and who documents the service, and the patient record must be signed by both parties. Before hiring a scribe, verify that scribes are allowed by your insurance or Medicare carriers and check the documentation guidelines.
In today’s world of healthcare reform, employing a scribe is just another avenue a physician can seize to conquer documentation rules and regulations. If you any further questions about scribes or any coding matters, contact Melesia Tillman, CPC, CRHC, CHA, at (404)-633-3777 ext. 820, or via email at [email protected].
Melesia Tillman is the coding specialist for ACR.