University of Kentucky / UK HealthCare Policy and Procedure. Policy # A05-190

Transcription

1 University of Kentucky / UK HealthCare Policy and Procedure Policy # A Title/Description: Use of Scribes Purpose: The purpose of this policy is to provide for proper documentation of clinical services when the billing provider has elected to utilize the services of a scribe. Policy Definitions Scribe(s) Procedure Persons and Sites Affected Policies Replaced Effective Date Review/Revision Dates Attachment A: Scribe Agreement Policy The use of scribes by physicians within UK HealthCare is permitted. Residents, interns and fellows may not act as scribes. Students, including but not limited to medical students and nurse practitioner students, on clinical rotations shall not act as scribes. Scribed documentation must clearly indicate the name of the scribe, the role of the individual documenting the service and the provider of the service. The physician is ultimately responsible for all documentation and must verify the scribed note accurately reflects the services provided. Providers other than physicians are not permitted to use the services of a scribe. Definitions Scribe(s) For the purpose of this policy, a scribe is defined as an individual who is present during the physician performance of a clinical service and documents on behalf of the physician everything said or performed during the course of the service. Procedure Any individual serving as a scribe must not be seeing or treating the patient in any clinical capacity, must not fill any role other than as the scribe (such as acting as the clinical assistant) during the patient encounter and must not interject their own observations or impressions. As mentioned above, students, including but not limited to medical students and nurse practitioner students, on clinical rotations shall not act as scribes. Policy # A Use of Scribes 1

2 1. Any individual performing the services as a scribe must review UK HealthCare policies and procedures on the use of a scribe and sign the Scribe Agreement (Attachment A) which states that the scribe will adhere to the policy and has received the required training. Requisite training shall include, but not be limited to, familiarity with the specific hospital organization or clinical area served, applicable UK HealthCare electronic medical record system, proper documentation of evaluation and management services provided in the specific hospital organization or clinical area serviced, and UK HealthCare compliance requirements. Each physician using the services of a scribe shall also sign the Scribe Agreement. Each department is responsible for maintaining a copy of the agreement, including a copy in the scribe s personnel file, and providing a signed copy upon request. 2. A scribed note must clearly and accurately reflect the service provided on a specific date of service. A scribe cannot enter an order into the electronic medical record (EMR). 3. A scribed entry can be hand-written contemporaneously or created/typed in the EMR. Scribes are not allowed to use dictation as a method for documenting. All scribed entries regarding a patient s health information must be completed in the presence of and at the direction of the physician. 4. Documentation by the scribe must include the following: (a) A personal, dated and timed note or entry from the scribe that: (i) Identifies them as the scribe of the service. (ii) Identifies the physician rendering the service. (iii)identifies the date and time the service was provided. (iv) Contains the scribe s signature (b) Co-signature of the billing physician (c) The following statements must be on each document created by a scribe whether handwritten or directly entered into the electronic record. (i) Scribe Attestation Statement: This note was dictated to me, acting as scribe for. (ii) Physician Attestation Statement: The documentation was recorded by acting as scribe in my presence at the time of the encounter and accurately reflects the service I personally performed and the decisions made by me." 5. The billing physician is ultimately responsible for the content of the scribed note. The billing physician s note should indicate: (a) Verification that the information was reviewed. (b) Verification of the accuracy of the information. (c) Any additional information needed. (d) Authentication including signature, date and time. The physician shall authenticate via an attestation the scribed document with a signature, date, and time before the physician and scribe leave the patient care area. The scribe cannot enter the signature, date and time for the physician and authentication cannot be Policy # A Use of Scribes 2

3 delegated to another physician. A physician signature stamp is not permitted for use in the authentication of scribed entries; rather, the physician must actually sign in writing or authenticate through the EMR system. 6. Individuals can only create a scribe note in an EMR if they have a password/access to the EMR. Documents scribed in the EMR must clearly identify the scribes identity and authorship of the document in both the document and the audit trail. 7. Physicians who use scribes are required to document in compliance with federal, state, and local laws as well as with UK HealthCare policies and applicable accreditation standards. 8. Departments or clinics utilizing the use of scribes shall ensure the scribe is not acting outside the scope of the scribe s job duties/functions through orientation, training and periodic performance reviews in accordance with applicable policies and procedures. 9. Competency assessments and performance evaluations of the scribes shall also be performed in accordance with applicable policies and procedures. 10. The Scribe must be regulatory compliant with all aspects of UK Healthcare information management, HIPAA, HITECH, confidentiality and patient s rights standards as do other UK HealthCare personnel, including hospital personnel. The Scribe must treat all information, data and training materials used in the scope of the Scribe position with complete confidentiality and security. Policy # A Use of Scribes 3

4 Persons and Sites Affected Enterprise Chandler Good Samaritan Kentucky Children s Ambulatory Department Policies Replaced Chandler HP Good Samaritan Kentucky Children s CH Ambulatory KC Other Effective Date: 06/08/2015 Review/Revision Dates: 06/08/2015 Approval by and date: Name Rhonda Killingsworth, Enterprise Director, Health Information Management Name Colleen Swartz, Chief Nurse Executive Name Bernard Boulanger, MD, Chief Medical Officer Name Marcus Randall, MD, Chief, Ambulatory Services Name Anna L. Smith, Chief Administrative Officer Name Michael Karpf, MD, Executive Vice President for Health Affairs Date Policy # A Use of Scribes 4

5 Attachment A: Scribe Agreement I hereby certify that I have reviewed the UK HealthCare policy Use of Scribes, A and have received the required training. I understand that as a scribe I am: 1. Required to be present during the physician s performance of a clinical service and document on behalf of the physician everything said during the course of the service. 2. Not seeing/treating the patient in any clinical capacity and must not interject my own observations or impressions. 3. Not filling any role other than as the scribe (such as acting as the clinical assistant) during the patient encounter. 4. Documenting my scribe service by including a personal dated and timed note or entry that: (a) Identifies me as the scriber of the service, (b) Identifies the physician rendering the service; (c) Identifies the date and time the service was provided, and (d) Contains my signature. 5. Ensuring the following statement is on each document created by me as scribe whether handwritten or directly entered into the electronic record. Scribe Attestation Statement: This note was dictated to me, acting as scribe for. 6. Aware that documenting in the electronic medical record (EMR) requires having a password/access to the EMR. Documenting under someone else s log in is prohibited. 7. Aware that the physician must authenticate the scribed document with a signed, dated and timed note. I cannot enter the signature, date and time for the physician. 8. Aware that I cannot enter an order into the EMR. 9. Required to be compliant with all aspects of UK HealthCare information management, HIPAA, HITECH, confidentiality and patient rights standards as do other UK HealthCare personnel, including hospital personnel. I must treat all information, data and training materials used in the scope of my scribe position with complete confidentiality and security. Scribe : Scribe Name: (PLEASE PRINT) Department: Date: (Page 1 of 2 of Scribe Agreement) Policy # A Use of Scribes 5

6 I, the undersigned provider, agree that the scribe will only perform the duties described in the UK Healthcare policy Use of Scribes, A I also agree that I am solely responsible for the accuracy, review and authentication of all health record information captured and/or entered by the above named scribe. Provider Name: (PLEASE PRINT) Provider : Date: (Page 2 of 2 of Scribe Agreement) Policy # A Use of Scribes 6