Scribes

catladyrn

A question came up today with respect to scribes: if scribes are trained in documentation principles, and are working directly with and for the physicians, rather than with or for coding or CDI, are they allowed to prompt the physician in real time when they realize the physician has dictated a diagnosis that might otherwise require a CDI query? We would not want to do anything that would be a compliance fail. I've reviewed AHIMA's guidelines on using medical scribes and they don't really address this question.

Renee

Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation, Core Measures and Outcomes
Tanner Health System

martin.conroy

Tell the scribe to go for it. Promise the scribe cookies if they do a good job.

I encourage everyone that works in my facility (nurses, nutritionists, PAs, nurse managers, .......) to help coach the physicians. What could possibly be wrong with a healthcare professional trained in documentation principals from engaging in documentation improvement. If the note does not reflect the true clinical picture of the patient everyone should want it improved.


Marty

catladyrn

My concern is that they might be considered part of the query process, and therefore might be offering a leading query by making a suggestion at the time of the dictation. The scribes may be trained in documentation principles, but they're not part of the CDI or coding team and don't have knowledge of CDI or query principles. I wanted to know if anyone had ever come up against this question as I can't find anything in my research.

Renee

Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation, Core Measures and Outcomes
Tanner Health System