Wiki Scribe statement

[WFassnacht]

I am in need of help. We have been told that a Resident can not be a scribe for a doctor and if there is a statement on a note stating the the Resident was just scribing for them it is non billable. Is this correct? This information came from our Compliance dept. after they reviewed a couple notes.
WOULD REALLY LIKE TO KNOW WHAT OTHERS THINK ....

 

[mcpalmeter]

Scribe Statement

In my humble opinion, residents should not be used as scribes to begin with because their job is to learn how to be a physician, not act as an administrative assistant for the teaching physician. They get practice writing notes by writing their own notes. Second, because the resident's thought process can get intermingled with the teaching physician's and end up as part of the teaching physician's documentation, I would say refrain from using clinical personnel like residents and NPPs as scribes. Lastly, the teaching physician documentation requirements for E/M services specifically state that the teaching physician must document his/her presence and participation and that the resident's documentation of this is not sufficient. The teaching physician guidelines make no exception for when a resident is documenting as a scribe. For these reasons I suggest you stay clear of residents as scribes.
Just my humble opinion as a coder who has a little bit of experience with compliance.

Maryann

 

[WFassnacht]

I am so happy to read what your opinion on this matter. Just wanted to state we are a teaching hospital and we do know CMS pays you for residents. We feel that they may question why a resident is acting as scribe when in fact they are suppose to be learning. Do you have any websites I may be able to pull information off of in order to show our doctors? That is one thing our doctors like to see information backing up what we are telling them. Again thanks!!
Flyers01