BC Advantage - 2012 Issue 7
Documentation and the Scribe
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Article Overview
This article discusses documentation workflow concerns involving scribes, electronic health records, and provider review of patient history and exam information. It is aimed at medical office staff, coders, auditors, and documentation trainers who need to understand the risks of inaccurate record entry, the importance of provider review, and broader compliance implications.
Why This Topic Matters
Accurate documentation affects medical decision-making, audit readiness, and legal defensibility. The article highlights why chart content entered by support staff must reflect what the provider actually reviewed and documented.
Article Sections
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Introduction and client documentation concerns
The opening discussion describes documentation observations made during client training visits and identifies issues seen in electronic record workflows.
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Getting Personal
This section recounts a personal encounter used to illustrate similar documentation practices in a real office setting.
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The Trend
The article broadens the discussion to the history and review-of-systems portions of an encounter and explains why provider review matters in general terms.
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An Illustration
A clinical example is used to show how record content and provider awareness can diverge in an encounter involving a common infection diagnosis.
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Getting Personal Again
The author revisits the exam portion of the visit to discuss the impact of documentation entered without direct provider verification.
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Generally Speaking
This section considers how inaccurate exam documentation could appear in a legal or malpractice setting.
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Who is Supposed to Perform the Exam?
The article explains the distinction between copying information and authoring exam findings, with emphasis on provider responsibility and record integrity.
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My View
The closing discussion focuses on auditing, completeness, truthfulness, and general documentation expectations in provider records.
What You Will Learn
- How scribe-driven workflows can affect documentation accuracy
- Why provider review of recorded history and exam content is important
- How electronic record habits may influence audit and legal risk
- What broad documentation elements are expected in a complete patient record
Who Should Read This
- Medical scribes
- Physicians and other providers
- Medical auditors
- Medical coders
- Practice managers
- Compliance staff
- Billing and documentation trainers
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