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ED Coding and Reimbursement Alert

EMR Compliance:

Using Scribes In The ED: What Documentation Can Be Counted By The Attending Doctor?

Published on Wed Mar 21, 2012

Take note of these rules when considering what the scribe can scribble. If your ED has moved to electronic health records, you may be considering using a scribe --a person who accompanies the doctor on each patient encounter -- to transcribe the doctor's History and Physical Exam into the medical record and expedite what can be a time-consuming documentation process. Before implementing scribes in your ED, be aware that many payers have specific rules about how the scribe process should work, and not knowing those rules can derail your claims. Todd Thomas, CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK, offers the following tips for structuring a scribe program the right way: 1. The scribe's documentation should begin by identifying the scribe and the physician. 2. A scribe must document verbatim what is being said by the physician. 3. When using an electronic medical record, the scribe must have [...]
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