June 2018

June 2018

How Your Chiropractic Scribe Can Streamline Documentation

In searching for ways to streamline documentation, and improve productivity, as well as patient satisfaction and care, there has been an increase in the utilization of medical scribes in recent years. If you are not already doing so, you may wonder if it is possible for the use of a scribe to truly help streamline your documentation. If so, then continue reading, and allow KMC University to shed some light on the subject for you.

WHAT IS A SCRIBE?

By definition, a Medical Scribe is a paraprofessional who specializes in charting physician-patient encounters in real time, such as during medical examinations. While a scribe may not act independently, they are tasked with proper documenting a provider’s dictation and/or activities.

The primary duty of the scribe is to document in a patient’s medical record. Although some scribes may have a medical background, they are not medical providers and nor do they treat patients. While there are no certification guidelines, or licensing required to become a scribe, comprehensive training is critically important. Scribes must have knowledge of practice procedures, understanding of general anatomy as well as have a solid grasp of documentation guidelines.

SCRIBES & COMPLIANCE

If you are going to utilize a scribe, it is critical to incorporate this into your compliance program. This includes creating a clearly defined policy detailing the responsibilities, certification (or lack of), and limitations of the scribe.

Just as required of all other employees, your scribe must complete an orientation process specific to their role in within the practice, receive regularly documented compliance training, and performance reviews.

ABILITIES & LIMITATIONS

There are several things a scribe can and must do, as well specific guidelines stating what they cannot do.

The scribe should clearly record, in detail, the doctor/patient encounter during examination and treatment. That being stated, they may not document any encounters outside of the exam room, independently. Nor should they duplicate any previous documentation encounters that do not pertain to the current one or record any information prior to provider/patient interaction. A scribe should document only in real time, as the provider dictates.

The scribe should accurately date all encounters in the patient’s medical record, as well as provide their signature and title separately from that of the physician. The provider should be certain to authenticate the scribe’s signature with his/her own, as well as document the date and time, before leaving the examination/treatment area.

Because guidelines of a scribe’s role may vary per region, it is always best to make certain you consult your local Medicare Administrative Contractor for specifications. Here are a few excerpts taken from MAC policies:

Cahaba GBA:

Documentation of scribed services must include:

  • Name of the person that performed the service
  • Name of the person that recorded the service
  • Qualifications of each person
  • The document must be signed and dated by both the physician and the scribe

WPS Medicare:

In an office setting, the physician’s staff member may independently record the Past, Family and Social History (PFSH) and the Review of Systems (ROS), and may act as the physician’s ‘scribe,’ simply documenting the physician’s words and activities during the visit.

Palmetto GBA:

If ancillary staff is present while the physician is gathering further information related to the HPI or any of the three key components, he/she may document (scribe) what is dictated and performed by the provider. The provider then needs to review the information as it is written, documented, recorded, or scribed and write a notation that he/she reviewed it for accuracy, add to it if supplemental information is needed and sign his/her name. The name of the scribe must be identified in the medical records.

Novitas:

While the provider or non-physician practitioner must perform the medical service, the scribe may document the dictation and what was performed in the medical record.

CGS:

The scribe is functioning as a ‘living recorder,’ documenting in real time … This individual should not act independently, and there is no payment for this activity.

IN CONCLUSION

Clearly, we can see the potential for scribes to contribute to helping providers improve both the quality and quantity of time they are able to spend with each patient, and as result, it should not be surprising if we begin to find the use of scribes more common.

As the provider’s time to focus solely on patient care increases, so does the patient’s satisfaction. Additionally, as the provider is not tasked with both treating the patient and documenting the encounter at the same time, services performed are often more accurately documented, which contributes to more proficient coding as well, minimizing risk.

Finally, we recognize that many providers are not comfortable using EHR and prefer handwritten notes. This is a personal business decision that you will need to make based on what works best for your clinic. If you determine that paper is the way to go for you, KMC University recommends our Paperwork System. It is a user-friendly system that will work well, should you decide to utilize scribe or record your own documentation. Click HERE to see the system.