Many providers of Medicare services utilize scribes to assist with everyday documentation. There are various reasons why a provider may benefit from using a scribe such as efficiency, legibility and the additional time to focus on patient care.

The Centers for Medicare and Medicaid Services (CMS) offered the following guidance to contractors when reviewing evaluation and management services when documented by scribes in the medical record.

1. If ancillary staff is present while the provider is gathering further information related to the patients visit (e.g., the three key components) he/she may document (scribe) what is dictated and performed by the physician or NPP
2. The provider needs to review the information as it is written, documented, recorded or scribed and write a notation that they reviewed the documentation for accuracy, add to it if supplemental information is needed, and sign their name
3. The name of the scribe must be identified in the medical records. (Note: Although not required the date of the signature should be noted.)
4. Ancillary staff does not need to be employed by the physician (example hospital employee) in order to fill the ‘scribe’ role

• CMS 1995 & 1997 E/M Guidelines