Wiki Use of a Scribe

[valerief07]

My physician is currently using his new PA as a scribe. My question is with documentation in an EMR. Should the scribe be under the physician when creating the encounter and then adding his blurb at the end that he was the scribe for ___ physician. Or should the PA be signed in the notes as himself and having the physician review and sign the notes. We have mixed opinions in our office. My bottom line is I do not want to be billing this out if the documentation is not correct. This is being billed under the physician I just want to double check we are documenting correctly.

 

[mhstrauss]

My physician is currently using his new PA as a scribe. My question is with documentation in an EMR. Should the scribe be under the physician when creating the encounter and then adding his blurb at the end that he was the scribe for ___ physician. Or should the PA be signed in the notes as himself and having the physician review and sign the notes. We have mixed opinions in our office. My bottom line is I do not want to be billing this out if the documentation is not correct. This is being billed under the physician I just want to double check we are documenting correctly.

I had to research this awhile back, and from what I remember reading, whoever is typing (not necessarily the same person performing the visit) should be logged in. So in your case, the PA would be logged in as himself while scribing, add his blurb about being a scribe, put the note on hold, then the MD can log in, add his own blurb about the scribe, then both need to sign the note. I'll try to find the resources I had back then; If i can find I will post here for you.

 

[mhstrauss]

Here's my MAC's guidance on scribes; I know other MAC's have similar articles if yours if different:

http://www.novitas-solutions.com/we...-state=axovyul19_75&_afrLoop=679368966241000#!


I never could find anything from CMS stating that the scribe must log in themselves, but there are numerous "nonregulatory" articles advising that this is the best way to go about it. Here's a good one from AHIMA. You can google "scribes in EHR" for others.

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049807.hcsp?dDocName=bok1_049807

HTH some!