February 10, 2022

Question:
We are hiring a scribe for the doctor because it will help improve his documentation.  Is there anything we need to know about how to document this?

Answer:
Yes, absolutely. This situation should be clearly delineated so a third-party reviewer can identify the provider who performed the service, and the record should be signed by both parties (the scribe and physician).

Remember, a scribe does not ask the patient any questions, nor does a scribe do an examination of the patient. A scribe merely records the information obtained by a provider. Bottom line is that a nurse practitioner or physician assistant generally does not act as a scribe.

Example of statements:

I, (scribe name), am serving as a scribe to document services personally performed by (physician name), based on my observation and the provider’s statements to me.

and

I, (physician name), attest that (scribe name) is acting in a scribe capacity, has observed my performance of the services, and has documented them in accordance with my direction.

*This response is based on the best information available as of 02/10/22.