Tips to elevate the quality of your scribes’ documentations

Many ophthalmic practices utilize scribes to document patient interactions, which helps to increase efficiency and improve charting. Over the years, our chart audits identified scribing patterns and led to a list of actions that can improve record accuracy and compliance.

Know the scribe’s role

The American Health Information Management Association describes the core responsibility of scribes as to capture accurate and detailed documentation of the encounter in a timely manner. Medical practices may assign additional duties to scribes that may include:

• Assisting the physician in navigating the EMR
• Responding to various messages as directed by the physician
• Locating information for review (ie, previous notes, reports, test results, and laboratory results)
• Entering information in the EMR as directed by the physician
• Researching information requested by the physician.

Scribes are not permitted to make independent decisions or translations beyond what is directed by the physician. They may not make diagnoses or decisions related to patient care and are not usually expected to perform tasks assigned to other clinical staff, such as interviewing or educating patients, taking measurements or administer diagnostic tests.

Compliance actions: Review and, if necessary, revise job descriptions for clinic staff and confirm that everyone is working appropriately within their assigned role.

Clearly chart who did what

Scribes may enter notes in the record on behalf of the provider but not act as the provider. The identity of the provider and scribe should be evident in the medical record. Novitas Solutions, a Medicare Administrative Contractor (MAC),¹ provides this advice for documenting the work of scribes:

Documentation of a scribed service must clearly indicate:

• Who performed the service
• Signed and dated by the treating physician or non-physician practitioner (NPP) affirming the note adequately documents the care provided
  • I agree with the above documentation’ or ‘I agree the documentation is accurate and complete’*

If an NPP is utilized and acting as a scribe for the physician, the medical record should clearly indicate the NPP is acting as a scribe. This applies to all scribed encounters, whether scribing was performed by licensed clinical staff or other ancillary staff.

*Examples

Billing provider’s note: “___________, acted as scribe for this encounter on _________”,

Billing provider’s note: “___________(scribes name) scribing for ___________(physician/non physician provider name)

It is recommended to include the identity of the scribe within the medical record documentation as the recorder of the service performed. It is expected that the use of a scribe to be clinically appropriate for each situation and in accordance with applicable state and federal laws governing the relevant professional practice, hospital bylaws and any other relevant regulations.

Check with your MAC for their documentation requirements. Additionally, consult your compliance plan for instructions; hospital-based practices and teaching institution often set more restrictive policies.

Medical record systems require log-in credentials for all users. Scribes should log under their own credentials, not the provider’s credentials, and providers should appropriately sign off on the encounter. The CMS Manual (Transmittal 713)² also addresses the importance of provider signatures.

Compliance actions: Review your EMR security policy as it pertains to user credentials. Monitor to ensure staff are adhering to the rules, not sharing passwords, and signing off on notes as required.

Keep information current

In many ophthalmic practices, scribes struggle to keep up with the physicians on busy clinic days and enter complete, detailed notes. The copy-paste features in most EMRs systems allow providers to quickly populate data fields by forwarding information from previous dates of service. This practice is both helpful and potentially hazardous. While it could speed up the documentation process, the use of EMR copy-paste features could compromise the integrity of the notes if errors or contradictions are copied, leading to note bloat and inflated coding.

Concerns over the potential for charting errors and an impact on patient care led The Partnership for Health IT Patient Safety to conduct an analysis and disseminate information regarding safe practices for safer care using health IT. The objective of the analysis was to “characterize copy and paste events in clinical care, identify safety risks, describe existing evidence, and develop implementable practice recommendation for safe reuse of information via copy and paste.” They developed safe practice recommendations, including:

• Provide a mechanism to make copy and paste material easily identifiable
• Ensure the provenance of copy and paste material is readily available
• Ensure adequate staff training and education
• Ensure copy and paste practices are regularly monitored, measured, and assessed.³

Compliance action: Create a written policy for EMR users, and stick to it. Ideally, minimize use of copy-paste. Consider employing drop-down menus or pick lists as an alternative approach, and distinguish copied information from newly entered information. Periodically audit the work of the staff; this may require shadowing during patient encounters to observe how work is being done.

Get the full story

In the exam lane, the scribe is responsible for documenting what the physician dictates. This includes summarizing the conversation with the patient regarding diagnoses and treatment options. The American Medical Association’s current guidelines for using medical decision making to support the E/M code selection uses the “consideration” of care as a factor in the management level, not simply the final decision treatment. Scribes should take care to record all the possible options selected and those considered but not selected after discussion with the patient and/or family. This requires the scribe be present and attentive to the entire discussion.

Compliance actions: Review the tasks assigned to the scribes. Reassign tasks that distract their attention from the physician’s exam and patient conversations so the scribe’s full attention can be dedicated to proper charting.

Conclusion

Consider these recommendations to elevate the quality of your scribe’s documentation, the validation, and verification of the note’s accuracy. Whether the physician personally writes it, a scribe writes it, or it is an electronic record keyed in by a scribe or physician, remember that the physician is ultimately responsible for everything documented in the medical record. OP

REFERENCES:

1. Novitas Solutions. Scribe services. https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00003295 . Accessed October 10, 2023.
2. Centers for Medicare & Medicaid Services. CMS Manual System. Pub 100-08 Medicare Program Integrity. Transmital 713. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R713PI.pdf . Accessed October 10, 2023.
3. Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Safe Practices for Copy and Paste in the EMR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration. Appl Clin Inform. 2017;8:12-34. Published 2017 Jan 11.

Mary Pat Johnson, COMT, CPC, COE, CPMA is a Certified Professional Medical Auditor and a Certified Professional Coder by the American Academy of Professional Coders. She has also obtained the Certified Ophthalmic Executive (COE) designation. Ms. Johnson conducts business from the Corcoran Consulting Group’s North Carolina office.