USING A SCRIBE
Question: I know the emergency department at my hospital allows the use of unlicensed persons to enter information into the medical record for the physician and there is talk of expanding this throughout the hospital. Can I utilize such a person in my practice?
You are referring to the use of what is known as a “scribe.” The Joint Commission (“JC”) recently issued a new FAQ entitled “Use of Unlicensed Persons Acting as Scribes.” It states that a scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner (defined by the JC as a Licensed Independent Practitioner, Advanced Practice Registered Nurse or Physician Assistant) and who can be an employee of the healthcare organization or of the physician/practitioner or can be a contracted service. The JC does not endorse nor prohibit the use of scribes, but acknowledges that scribes can be used in the ER or elsewhere in the hospital “with the goal of allowing the physician/practitioner to spend more time with the patient and have accurate documentation.” The FAQ goes on to state that the scribe “may not act independently but can document the previously determined physician’s or practitioner’s dictation and/or activities . . . and assist in navigating the EMR and in locating information such as test results and lab results. They can support work flow and documentation for medical record coding.” To read the entire JC guidance on scribes, go to their Standards FAQ Details webpage: www.jointcommission.org
Before utilizing a scribe in your practice, however, you must be aware of any edicts from your licensing board, from your hospital, and from the applicable payor. For example, National Government Services published documentation requirements when a scribe is used: www.ngsmedicare.com
and Novitas recently updated its Provider Bulletin on scribes: www.novitas-solutions.com
. Within your office, you must ensure that the scribe has adequate skill and training and is subject to the same confidentiality obligations as any other employee or contractor. And you must have clear, written protocols in place, including but not limited to outlining physician authentication requirements and prohibiting the scribe from entering physician/practitioner orders into the record. Remember that you ultimately are responsible for documentation in the medical record, which may be why Novitas has also just released a new Sample Signature Attestation Statement: www.novitas-solutions.com
Kern Augustine Conroy & Schoppmann, P.C., Attorneys to Health Professionals,www.DrLaw.com, is solely devoted to the representation of physicians and other health care professionals. The authors of this article may be contacted at 1‐800‐445‐0954 or via email at info@DrLaw.com.