Use of Scribes

April 8, 2004

The teaching physician may use a scribe to assist in the documentation of a patient service. The following categories of individuals may not act as scribes:

• Residents
• Interns
• Fellows
• Medical Students

A scribed note must include the following:

• An authenticated and dated personal note from the scribe that he/she was acting as a scribe on behalf of a teaching physician (e.g. In the presence of Dr. Faculty, I am taking down these notes.); and,
• A signed attestation by the teaching physician indicating that the note accurately reflects the physician's personal service and that it was scribed on their behalf (e.g. I performed the above scribed service and agree with the accuracy of the note.)

The resident, fellow, intern and teaching physician should document the level of service that he/she provided. The combined documentation will be used to code the service.