This Rapid Tutorial will outline the role of the scribe and how the scribe can help the clinic and doctor document more efficiently. We also discuss what areas of compliance that a clinic must consider when utilizing a scribe.
What is a Scribe?
A scribe is not a medical provider. The Joint Commission, which accredits and certifies healthcare organizations and programs, released the following statement in July 2012: “A scribe is an unlicensed person hired to enter information into the electronic medical record (EMR) or chart at the direction of a physician or practitioner. It is the Joint…
Helpful Documentation Tools
Download Reference Documents Sometimes, when reviewing records to be sent, it’s clear that the note(s) were not properly signed and authenticated. In this instance, all is not lost. Even Medicare provides a way to offer Signature Authentication after the fact. If you have not already reviewed the module in this course regarding signatures, please do…
Samples: Documentation and Informed Consent
Templates and Support Tools to Help Two of the most important locations for proper documentation of the CMT are when it’s prescribed in the initial treatment plan, and when it’s described on a Routine Office Visit (ROV). We provide documentation samples throughout the KMC University Library, examples of the necessary components of a note for…
Documenting Physical Medicine – Routine Office Visit (ROV)
Documentation & Coding of Physical Medicine- ROV Now that we’ve learned the importance of properly ordering and providing rationale for modalities and procedure in the initial visit, let’s explore best practices for documenting which services were performed on daily visits. Various regulations exist that point toward what type of information must be included to qualify…
CMT Documentation Resources
Support Tools Two of the most important locations for proper documentation of the CMT is when it’s prescribed in the initial treatment plan, and when it’s described on a Routine Office Visit (ROV). We provide documentation samples throughout the KMC University Library, examples of the necessary components of a note for clinically appropriate and medically…