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UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Administration

UW Health Scribe Policy (1.55)

UW Health Scribe Policy (1.55) - Policies, Administrative, UW Health Administrative, Administration

1.55

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Administrative (Non-Clinical) Policy

This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).

Policy Title: UW Health Scribe Policy
Policy Number:
1.55
Effective Date: November 20, 2017
Chapter: Administration
Version: Revision

I. PURPOSE

To ensure proper documentation of clinical services when the billing provider elects to utilize the services
of a scribe. The appropriate use of a scribe allows the physician or Advance Practice Practitioner (APP)
to spend more time with the patient and ensure accurate documentation.


II. DEFINITION

Scribe - An individual, who neither acts independently nor functions as a clinician, but simply records the
provider’s words and/or activities during the visit to make the documentation ready for provider review at
the end of the service. The following individuals are prohibited from acting as a scribe:

Residents, Fellows and Students (e.g. Medical Student, Nurse Practitioner (NP) Student, Physician
Assistant (PA) Student)

Any individual who bills professionally through UWMF (e.g. NP, PA, Speech Pathologist (SP))


III. POLICY ELEMENTS

The Operations Vice President for the clinical area must approve the use of scribes. All medical records
prepared by the scribe must be clear, complete and appropriate with regard to authorship and service
delivery. The medical record must clearly reflect the performance of the billed service and the medical
necessity for rendering the services. Scribes must document under a separate security template by
selecting their Clinical Scribe job title.




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IV. PROCEDURE

A. Prior to functioning in a scribe capacity, all UW Health-employed individuals must complete
online training available in the Learning and Development System. Training must be completed
annually thereafter. Scribes contracted through an outside vendor must complete the vendor’s
training program.
B. Prior to utilizing a scribe, physicians and APPs who utilize scribes must complete annual online
training regarding the scribe policy.
C. Once training is complete, supervisors must request to have the Clinical Scribe security added to
the employee’s Health Link access prior to them functioning as a scribe.
D. Providers and scribes are required to document in compliance with all federal and state laws, as
well as UW Health policy.
E. The physician or APP who receives the payment for the services is expected to be the person
delivering the services and creating the record by directing another person (the scribe) what to
enter into the medical record as the service takes place.
F. The scribe does not act independently in Evaluation and Management (E&M) services, surgical,
and other such encounters, but documents the provider’s dictation and/or activities during the
visit without interjecting their own observations or impressions.
G. Individuals functioning in a scribe capacity are prohibited from entering orders while functioning
as a scribe.
H. Documentation
1. The scribe must enter the documentation under their own Health Link username and
password and their note should include:
a. The name of the scribe and an electronic signature
b. The name of the physician providing the service
c. The date the service was provided
d. The name of the patient
1. The following is an example to comply with these requirements:
“I am acting as a scribe for the service performed by Dr. Smith.”
2. The provider of service is ultimately responsible for all documentation and must verify that
the scribed note accurately reflects the service provided. The billing provider’s note should
indicate:
a. Verification that he/she reviewed the information
b. Verification of the accuracy of the information
c. Any additional information needed
1. The following is an example to comply with these requirements:
“I reviewed this note and it accurately reflects the service I performed.”
3. The scribed documentation must be authenticated by the billing provider in accordance with
the current documentation guidelines.
4. Appropriate Scenario
• An individual, functioning as a scribe, documents the performing provider’s service to
the patient in real time. Following the visit, the performing provider reviews the
documentation, adds his/her attestation, enters orders as necessary, chooses the billing
codes and closes the encounter.

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5. Inappropriate scenario
• Nurse Practitioner (NP) obtains the patient’s history and performs the physical
examination. The faculty physician repeats key examination components and provides
medical decision making and the NP then scribes the physician’s examination and
medical decision making.

VI. REFERENCES
The Joint Commission, “Use of Unlicensed Persons as Scribes.” July 12, 2012
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=426&P
rogramId=47
NGS, Policy Education Topics: Scribing Medical Record Documentation
Scribing Medical Record Documentation
Compliance Coding and Documentation Dispatch, December 2013

V. MODIFICATIONS

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and
Clinics Authority and the University of Wisconsin Medical Foundation, Inc. Each entity is responsible
for enforcement of this policy in relation to the facilities and programs that it operates.

VII. COORDINATION

Sr. Management Sponsor: SVP, Chief Clinical Officer
Author: Director of Compliance Professional Services
Reviewers: VP Clinical Operations, Legal Department

Approval Committee: Professional Services Compliance Support Committee, UW Health Administrative
Policy & Procedure Committee


SIGNED BY
Elizabeth Bolt
UW Health Chief Administrative Officer