Scribes: Improve Documentation, Increase Compliance

Jane T. Shuman, COE, COT
8/15/2003

Employing a staff person in the ophthalmic office specifically to take notes on exams and assist the physicians—a scribe—can improve the practice's documentation and compliance as it relates to chart audits. The potential for increased productivity and revenue is such that a practice that begins using a scribe may wonder how it ever got along without one.

One of the initial phases of the Health Insurance Portability and Accountability Act mandated that all medical practices have a compliance plan in place to deal with complaints from patients, staff and others regarding questionable medical practices, fraud and abuse issues and incorrect billing. It became even more important for physicians to be able to justify the use of a particular procedural code. The standard cry among ophthalmic coding consultants became, "If it wasn't documented, it wasn't done." Also, thorough documentation is a protection for the practice in the legal realm. Should there ever be litigation, paper backup exists regarding what did or did not occur during an exam.

Where a Scribe Can Fit In
Consider the low-light setting of the ophthalmic exam and how difficult it is for the physician to both perform the exam and take copious, legible notes. The necessary documentation can be done easily when the doctor dictates his findings to a scribe accompanying him into the exam lane. In some practices, the scribe is an entry-level job; others choose to allow only certified ophthalmic medical personnel to write for the physician.

 A Common Language
Before you begin using a scribe in your practice, the providers and the management team must agree on a common "language" for an-atomical structure, ocular and systemic diseases, medications, and any terminology that might be practice-specific. This will insure that documentation is consistent no matter for which provider the scribe is writing. These abbreviations should in-clude the standard terms for healthy findings (e.g., dp & qt for the anterior chamber) as well as those phrases used to describe pathological findings (e.g., cell and flare). For compliance's sake, do not forget to update a listing of staff names, and corresponding signatures and initials. In the event of a chart audit, you may want to offer these lists to reviewers, since many do not have an ophthalmic background.

A Scribe's Exam Notes:
• What medical decision is taking place
during this visit?
• If surgery is discussed, has the doctor reviewed the risks and benefits?
• Does the patient make a decision to schedule surgery, or defer it, and why?
• Does the physician mention any alternatives?
• Are previous records or correspondence reviewed?
• Are tests ordered?
• What is the treatment plan? 
• Are medications prescribed or refilled? Record the specifics.
• Were glasses or contact lenses issued? Record the specifics.
Duties of the Scribe
History. Most examinations begin with the doctor reviewing the technician's notes about what brought in the patient. It is imperative that the scribe learns to edit the technician's history of present illness, noting any additional information that the patient offers the doctor. The scribe must record positive or negative responses to prove that the doctor actually asked certain questions. For example, the patient might reveal a change in marital status or physical health to the physician that she did not reveal when the technician took the history. A weak history may prevent the use of an otherwise-justified upper-level procedural code. For instance, a comprehensive history, but one which is missing the patient's family medical history, may necessitate a level-3 evaluation and management code instead of the otherwise-appropriate level 4.

Personal information. If the patient has given permission to speak with someone else regarding her condition, the name, telephone number and relationship to the patient should be documented. HIPAA has made this record especially important.

Standardization. Once the exam begins, the scribe must note the findings verbatim. The use of forced-entry exam forms helps greatly, particularly if there is adequate space for findings for either eye.

Match word and action. The scribe must remember to watch the exam closely and correlate verbal dictation with the eye actually being ex-amined (i.e., the physician might accidentally say OS when the scribe can see he is examining the right eye).

Don't assume. The scribe should not assume to mark as "normal" any element the doctor fails to dictate. It's also unacceptable for the scribe to copy findings from the patient's previous visit onto the current exam record.
Documentation does not end when all the instruments are set aside. The scribe should continue to take detailed notes of the physician's assessment of the progression of the disease as well as the presence of any conditions. For example:
• Cataract, OS>OD, now visually significant,
• OAG, need to lower IOP,
• ARMD, stable.

The scribe does not make these determinations, rather she listens to and summarizes the conversation between physician and patient. (See sidebar p. 24). The scribe should take especially detailed notes when tests are ordered—optic nerve scanning lasers, visual field tests, A-scan or IOL Master. A scribe can underscore her value to the practice by knowing things like that when fluorescein angiography is ordered, photos must also be specified. The smart scribe knows that in the event of a chart audit, standing orders are not recognized by insurance carriers.

An Assisting Role
Scribing is not only about documentation. The scribe constantly assists the ophthalmologist and the patients. She may hold a patient's head in the slit lamp or change tonometer tips. An experienced scribe will do things like locate the jewelers' forceps before being asked.

Often, it falls to the scribe to maintain patient flow, taking note of any backlog. The scribe may take care of relaying instructions to the patient, in-cluding lid hygiene, postoperative care or scheduling information for surgery or follow-up.

Do We Need a Scribe?
How do you determine if you should incorporate the use of a scribe into your practice? Look around your office. Are the charts piled around you, with no findings listed on any of the exams? Do you perpetually run late because you dictate or write your findings between patients? Is the increasing scrutiny of documentation preventing you from doing things you would prefer? In other words, is documentation keeping you from your child's soccer game? If you answered yes to any of these questions, consider transitioning a current employee into a scribe position, or hiring an additional person.

Time Saved by a Scribe
Average time physician spends with a patient = 13 minutes
Daily time physician spends
documenting visits = 75 minutes
75 ÷ 13 = 5.76
With the help of a scribe, you could see five or six more patients per day.
Of course, your productivity must increase at a rate that will cover the cost of an additional employee. Try this formula: Find the average amount of time you spend with your patients, in minutes. Next, find the total amount of time it takes you each day to document these visits. Divide the second number by the first. The result should be an indication as to how many more patients you can see in an average day (See sidebar).

Once you've hired the scribe, add the additional patients in slowly as you learn to work as a team. You may find that in actuality you can surpass the goal number, improving both your documentation and your productivity. 

Ms. Shuman is the practice manager at Dedham Medical Associates and the president of Eyetechs Inc., a consulting company to ophthalmology practices. She may be reached at jtshuman@attbi.com.