Q. When employing a scribe, what guidelines should I follow to minimize risk?
A. You’ve heard time and again that medical records can be your best friend or your worst enemy in the courtroom. When using scribes, physicians would be wise to employ the risk-reduction suggestions provided here.
Importantly, the author of every medical record entry should be clearly identified, regardless of length or perceived importance of the record. This provides not only identification of the author but also authenticity regarding what is written.
To that end, a scribed encounter note should indicate the involvement of a scribe. The scribe’s note should include the following minimum criteria:
- Name, title and signature of the scribe
- Name of the physician using the scribe’s service
- Date and time the service was provided
- Authentication, including date and time
Since the physician is ultimately responsible for the contents of the documentation, the physician’s note should reflect:
- Affirmation that the physician personally performed services
- Confirmation of a review and accuracy of the scribed information (Some physicians attach an attestation that they reviewed the entry(ies).)
- Acceptable physician signature or identification
For additional information on creation of a scribing policy and use of a scribe/physician agreement, please see the American Health Information Management Association’s website here.
Physicians insured by ProAssurance may contact our Risk Resource department for prompt answers to liability questions by calling (844) 223-9648 or via email.