Documentation and the Scribe

By Kathy Young

Recently I traveled out of state to visit a new client, to discuss their documentation with them so that I could help and train them on being more successful.  It was during one of my interviews with the Provider's scribe that I discovered some alarming practices that would need to be addressed. 
I asked the scribe to walk me through an encounter from beginning to end.  She showed me how she asks the patient the questions for the review of systems.  She then showed me the paperwork the patient brings in and how she takes that information and puts it into the Electronic Medical Records (EHR). She guided me through the paperwork and data input of the EHR of a new patient and an established patient.  For a new patient she enters the information from the sheet, and then she asks the patient the pertinent information to complete the review of systems.  She also asks them about their personal medical history, family medical history, and social history including allergies. 

It was at the established patient where it began to get messy in her EHR.  She stated that she simply keeps the items clicked from the previous visit and doesn't change anything.  I then asked the burning question, "Does the doctor go over each line item in the history as written by you?"  The answer was no.  He comes in and begins the exam whether the patient is new or established.  This is where red flashing lights and alarm bells started going off in my head.

But that's not all.  At the Exam portion of the visit, she automatically clicked the box for the skin or integumentary system as to whether it was clear or not.  I asked her if she is a nurse practitioner, PA, or physician.  She told me no.  So I asked her why she felt it was okay for her to click on the findings in the exam.  Her statement was that she noticed that the patients do not have any issues with their skin and she just noted it each time. 

I addressed this with the Provider and the proper processes that will be followed.  I assumed this was an isolated incident.  I was wrong.

Getting Personal
Two weeks later I visited a new doctor for my own health.  I watched the scribe do exactly as my client's scribe had done.  The doctor did not review the history with me or even look at the screen.  The scribe had already marked that my skin was clear. 

The Trend
I think there is a trend with the EHR that is so concerning to me as an auditor and teacher of documentation that I can barely breathe.  Let's look at the problem with what is happening in this trend.

The history of the patient's current illness is pinnacle in patient care. The Provider needs to know personally the onset of the illness, how long the patient has had this illness, and all the other questions that should be asked in the history of present illness by the Provider.

As for the review of systems (ROS), this must be reviewed by the Provider.  It is called "Review of Systems" and is not called "Report of Systems."  The ROS in the initial encounter is vital to the Provider's decision making.  The Provider needs to know if there are other underlying issues that need to be considered. 

Therefore not to review this information on any level would be a great disservice to the patient. This is also dangerous for the Provider as it could lead to malpractice.

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An Illustration
An excellent story that illustrates this is a medical record that I reviewed of a patient who came into the medical office with a UTI, or Urinary Tract Infection.  The Provider's medical decision was to give the patient an antibiotic and for them to drink lots of cranberry juice.  On the surface that doesn't sound too alarming.

However, in the review of systems, the patient stated that they were diabetic and were not well controlled. The Provider documented that he had reviewed the patient's medical history, but in truth the Provider must not have reviewed it or they would have known that the patient was diabetic. 
This is a weakness in this EHR era that we are currently in.  If the Provider had hand written or personally transcribed the history, he would have noted the diabetes.  But because he only had to click through a computer page, the system showed that he reviewed something he clearly did not.  Again, it is called a "review" of systems and not a "report" of systems.  The Provider must be the one who reviews the systems and not just the scribe.

Getting Personal Again
Let's go back to the Exam as performed by my scribe at my own doctor's visit.  If the scribe notes that my skin is clear, what does that matter if the Provider does not notice it?  What if I had clear skin on what was visible to the scribe? But during the exam, the Provider noticed that I had a rash but did not state this to the scribe.  Meanwhile, the scribe had already documented what she had seen from a non-professional view that the visible body areas were clear, and this may not be true.

Generally Speaking
What if this type of documentation ended up being a part of a court case for malpractice?  The notes state that the skin is clear but the patient states in court that they have psoriasis on their trunk.  How would this error in documentation look for the Provider? It would look like he did not pay attention. It would have been better for there to be no note on the skin than to have the note that is incorrect.

Who is Supposed to Perform the Exam? 
The Exam portion is for the Provider only.  The scribe should only write what the Provider has stated and never make a comment that was not made by the Provider.  A scribe is defined as "someone copying documents and books."  They copy; they do not write, create, or embellish.  To do so is a misrepresentation of services being rendered. 

Let's go back to the history portion of the encounter.  When the scribe, who is often a medical assistant, takes the information from the patient on his or her history and asks questions that may give clarity as to what is reported on the patient intake form, they are still scribing.  They are only putting down what is being stated or written. 

It is up to the Provider to read and review the record, to make comments as necessary, or ask more questions as needed.  However, the Provider should only get credit for the systems that they actually reviewed.  All other boxes should be unclicked.  If the Provider did not review it, there is no credit given for that level of service.  Again, the ROS means "review" and that means a review by the Provider.

My View
As an auditor, I find more and more that my job is not reviewing for levels of service, but reviewing for accuracy and truthfulness in documentation.  Practices want to take the short journey to the same destination that should not be the short trip.  Short cuts are dangerous, and scribes should not be part of the shortcut. 

Therefore in the Providers' documentation:

The Medicare Program Integrity Manual gives the recovery auditors great freedom to locate fraud or abuse by just about any means.  It is not fully clear what that intends but I think it means that we must be diligent in all areas of the practice, and never to embellish the story.  An embellished story is still a misrepresentation of the true story.  And that is the definition of fraud. 2

1See generally, OIG Compliance Program for Individual and Small Group Physician Practices, 65 Fed. Reg. at 59440
2 For this and more about audits, see Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions

Kathy Young, CEO, uses her experience and knowledge to teach and certify billers, with the certificate of CMBS (Certified Medical Billing Specialist). In addition, Kathy regularly teaches webinars educating billers state wide on new practices or techniques. Kathy Young is also the President of the East Valley Chapter of the Medical Association of Billers.