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Streamline Your Documentation

Providers are always searching for ways to lessen the burden of documentation, improve productivity, and enhance patient satisfaction and care. A viable option is to use a chiropractic scribe. When implemented compliantly, a scribe can help streamline documentation.

What is a Chiropractic Scribe?

A scribe is a team member who specializes in charting physician-patient encounters in real-time, such as during examinations and treatment. The primary duty of the scribe is to properly document, in a patient’s medical record, the provider’s dictation and activities. While there are no certification guidelines, or licensing required to become a scribe, comprehensive training is critically important. Scribes must have a solid understanding of practice procedures and general anatomy, as well as a solid grasp of documentation guidelines.

Utilizing a Chiropractic Scribe Compliantly

When utilizing a scribe, it is critical to incorporate this into your compliance program. It includes creating a clearly defined policy detailing the scribe’s responsibilities, required certification, and limitations. As with all other employees, scribes must complete an orientation process specific to their role within the practice and participate in regularly documented compliance training and performance reviews.

Because guidelines of a scribe’s role may vary by region, it is always best to consult your state laws and local Medicare Administrative Contractor (MAC) for specifications.

Here are a few excerpts taken from various MAC policies:

  • Documentation of scribed services requires:
    • Name of the person that performed the service
    • Name of the person that recorded the service
    • Qualifications of each person
    • Document signed and dated by both the physician and the scribe
  • In an office setting, the physician’s staff member may independently record the Past, Family and Social History (PFSH), and the Review of Systems (ROS), and may act as the physician’s ‘scribe,’ simply documenting the physician’s words and activities during the visit.
  • While the provider or non-physician practitioner must perform the medical service, the scribe may document the dictation and the procedures performed in the medical record.

Patient Satisfaction and Minimized Risk

We can see the potential for Chiropractic scribes to help providers improve both the quality and quantity of time they can spend with each patient. As the provider’s time to focus solely on patient care increases, so does the patient’s satisfaction. Additionally, as the provider is not tasked with both treating the patient and documenting the encounter at the same time, services performed are often more accurately documented, which contributes to more proficient coding as well, minimizing risk.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and practiced for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016. In November 2020, Dr. Auchenbach joined the excellent team at KMC University as a Specialist and, as part of this dedicated team, is determined to bring you accurate, current, reliable information. You may reach her by email at info@kmcuniversity.com or by calling (855) 832-6562.

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