Using a Scribe? – Documentation Reminder

On December 15th, 2010, posted in: Tips by jcullen

When using a scribe, it is important to keep in mind that the scribe cannot interject any personal observations or comments into the medical record. The scribe is simply to be used to document the services that the physician is providing. In addition, the physician must review the scribes documentation and then sign the note, indicating it has been reviewed and he/she is in agreement with what was documented. This will authenticate the note and it is a requirement for billing purposes.