Using a Scribe
Question:
I would like to know if it is compliant for the doctor to make corrections or additional comments on the note written by the scribe? For example, the note is written by the scribe, but at the end of the day the doctor reviews the note and makes correction if he sees a mistake or should he write a separate paragraph at the bottom of the note, summarizing or adding information onto the same note?
Answer:
Thank you for your inquiry. In answer to your question, yes, the provider must update any notes documented by a scribe. CMS states “The treating physician’s/non-physician practitioner’s (NPP’s) signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided”. In the EHR, corrections must be made according to the Medical Records Standards of Documentation; addendums must be noted as an addendum. Any corrections/addendums must be noted as such according to the documentation standards.
Since the provider is ultimately responsible for the contents of the documentation, the provider’s note should include:
- Affirmation of the provider’s presence during the time the encounter was recorded
- Verification that the provider reviewed the information
- Verification of the accuracy of the information
- Any additional information needed
- Authentication, including date and time
It is recommended that you check your payor policies regarding the use of scribes. As a reminder, a scribe may only document the spoken word of the provider and must be present during the entire encounter. A scribe also may not enter the electronic signature, date, and time for the physician or practitioner in the note and cannot perform any clinical duties for the patient while acting as a scribe.
