Scribes

Category: Compliance 

Date: December 2004

Reviewed/Revised: April 2013

Purpose

To outline the specific requirements to be followed when using scribes to document a physician service.

Policy

All documentation must clearly reflect the services rendered to the patient and the physician’s involvement in those services as well as the medical necessity for rendering the service.

Definition

A scribe is an individual who simultaneously transcribes information the physician dictates. A scribe may not have performed any of the services which he/she is transcribing.

Procedure

Scribes must indicate by third person reference that they are actually scribing while the physician is performing the service. The sign-off on the entry should indicate “XXX, RN scribing for Dr. YYY”. The physician must also sign the entry indicating that he/she was present, provided the documented service and approves the documentation.

Example

Patient name___________________________

Date of service_________________________

Chief complaint_________________________

Vitals_________________________________

Signature of nurse

History________________________________

Exam_________________________________

Assessment/plan________________________

XXX, RN scribing for Dr. YYY

I was present, provided the service documented above and approve this documentation.

YYY, MD