Awareness : OBC Tips

Use of Scribes

Individuals can only create a scribe note in an EHR if they have their own password/access to the EHR for the scribe role. Documents scribed in the EHR must clearly identify the scribe’s identity and authorship of the document in both the document and the audit trail. Scribes are required to notify the provider of any alerts that appear for the provider’s attention within the EMR. Alerts must be addressed by the provider. Providers and scribes are required to document in compliance with all federal, state, and local laws, as well as with internal policy. Verbal orders may neither be given to nor entered by scribes. Scribes may pend orders for providers based upon provider instructions. Example of attestation that shall be documented by the Scribe: “Scribed for [DR. XXX] by [Name of scribe] [date and time of entry]. Example of attestation that shall be documented by the Physician, before closing the encounter: “I was present during the time the encounter with [patient name] was recorded. I have reviewed and verified the accuracy of the information performed by me.” [Name of provider][Date and time of entry]. The provider and scribe must execute the appropriate Scribe Agreement or Provider Agreement.