MSRDP COMPLIANCE AND ETHICS COMMITTEE GUIDELINES

Use of Scribes
04/08/04

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.

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