# Can scribes document Physical Exams



## Mindy Davis (May 6, 2015)

I'm wanting a definitive answer on whether its legal for a scribe to document the physical exam if the provider documents an attestation statement?


----------



## mhstrauss (May 6, 2015)

Mindy Davis said:


> I'm wanting a definitive answer on whether its legal for a scribe to document the physical exam if the provider documents an attestation statement?



As far as I'm aware, a scribe can document any part of the service, with the appropriate attestation statement. I've never come across anything stating that they can only document certain parts of a record.


----------



## teresabug (May 6, 2015)

you need to check into the scope of practice for the state that your providers operate out of. Only a physician or NPP can document the HPI and physical exam elements. Clinical staff can chart the chief complaint and ROS but it ultimately the providers responsibility to make review all charting done by a non-provider.


----------



## mhstrauss (May 6, 2015)

There are no scope of practice guidelines for a scribe. Anyone can scribe for a provider--the provider is doing the work himself.


----------



## teresabug (May 6, 2015)

a scribe is actually doing the charting in the medical record, not the provider. Again, it is suggested by AAPC and the AHIMA to check into your states' regulations.


----------



## jimbo1231 (May 7, 2015)

*Scribes can*

I agree with Meagan. Scribes should not be documenting. Scribes are effectively "human tape recorders" so the documenting is being done by the provider. I think I just gave away my age with the "tape recorder" reference. For post baby boomers Scribes are human I-Phone sound apps.

Where the line gets fuzzy is when practices have mid-levels or students do scribing. But the reputable Scribe outfits don't do that are clear that Scribes are merely recording provider documentation.

Jim S.


----------



## kak6 (May 7, 2015)

too funny jimbo! I actually still have a tape recorder and Walkman ...
 Yes scribes can "record" any and all of the medical record. The medical provider (who ever it may be MD, PA, NPP need to clearly state they have reviewed and agree with scribe documentation and sign. then the scribe must state the name of provider they are scribing for and their name as scribe. this is called 'attestation statements'. One of the reasons providers hesitate to use medical assistants or students is they have a tendency to inject their own opinion (because they know) into the medical record, sometimes not realizing they are doing that. Scribes are schooled for 'scribing' and do a wonderful job of moving the day along in a timely manner for the medical provider.


----------



## amydenn07 (May 22, 2015)

A scribe cannot independently document any portion of the encounter except PFSH and ROS.  This link from Cahaba may provide some clarity but you should search your MAC's stance on scribes as well. https://www.cahabagba.com/news/guidelines-for-the-use-of-scribes-in-medical-record-documentation-2/

Amy Dennington, CPC, CEMC, CPMA


----------



## BenCrocker (May 22, 2015)

jimbo1231 said:


> I agree with Meagan. Scribes should not be documenting. Scribes are effectively "human tape recorders" so the documenting is being done by the provider. I think I just gave away my age with the "tape recorder" reference.
> Jim S.



I'm only 38/9 and I took shorthand in school and college. So I know what you mean Jim.


----------

