Scribe Services

A scribe can be a NPP (Non-Physician Practitioner), nurse or other ancillary personnel allowed by the physician to document his/her services in the patients' medical record.

These ancillary personnel do not have to be employed by the physician or NPP performing the service in order to scribe. Scribes are most commonly used in the inpatient hospital setting, but they may be utilized in any setting.

While the physician or NPP must perform the medical service, the scribe may document what is dictated and performed in the medical record. Documentation of scribed services must clearly indicate:
  • Who performed the service
  • Who recorded the service
  • Signed and dated by the physician/NPP

When an NPP acts as a scribe for the physician, the medical record should clearly indicate the NPP is acting as a scribe. Documentation is considered to be scribed when the NPP writes notes into the medical record while the physician is personally performing the service.

The use of a scribe has to be clinically appropriate for each situation and in accordance with applicable state and federal laws governing the relevant professional practice, hospital bylaws and any other relevant regulations.