Understanding E/M: Make sure scribes note only what physician dictates during visits

Why This Topic Matters

Scribe-assisted documentation can affect compliance, audit risk, and whether a service record properly reflects who performed and documented the visit. Understanding the documentation expectations helps practices support accurate records and align with contractor policy.

Article Sections

1. Using scribes during E/M visits

   Introduces the use of scribes in patient visits and describes the general documentation role they may play. The section contrasts supportive documentation with participation in clinical components of the encounter.

2. Documentation and authentication expectations

   Summarizes the kinds of record elements that Medicare contractor guidance addresses for scribed services. It also covers physician sign-off, record responsibility, and related documentation details.

3. NPP services versus scribe situations

   Explains the distinction between services independently performed by a non-physician practitioner and documentation performed in a true scribe scenario. The section also notes the billing and identification context discussed by the source.

4. Official resources

   Lists external contractor and professional organization resources referenced by the article. These resources provide additional policy and documentation guidance.