November 14, 2019
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?
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.
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 11/14/19.