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Certification Requirements for Scribes

Many practices utilize scribes for entering data into their medical records software. Doctors often feel the data entry takes too much time and slows them down during the exam. Others feel that the data entry turns them away from their patient and impacts their ability to connect with and focus on what the patient is communicating.

Whatever the reason, scribes are here to stay. If you are a Meaningful User of EHR you will want to be certain you are aware of the limitations to scribe data entry. CMS specifically limits the scope of data entry for CPOE – Computerized Physician Order Entry. CPOE relates to medications, lab and radiology orders.

CPOE is one of the Core Measures for both Stage 1 and 2, however, the guidelines vary by stage for which professionals are authorized by CMS to perform this documentation.

Stage 1

CMS guidelines state, “Any licensed healthcare professionals can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE if they can enter the order per state, local and professional guidelines.” More info available here

According to the American Academy of Ophthalmology’s Stage 1 MU Guidelines document, “Certified ophthalmic assistants and certified ophthalmic technicians are now permitted to enter medication orders for purposes of meaningful use.”

For Stage 1, the provider or a COA, COT will need to be the one(s) to CPOE into the EHR.

Stage 2

According to CMS guidelines found here, “Any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant. ”

Stage 2 expands the pool of staff eligible to enter this critical data into the EHR, to include Certified Scribes. This is great news for Ophthalmologists and Optometrists who employ techs who are not COA’s or COT’s and would like them to be able to enter the medication, lab or radiology orders (Like OCT’s) into the EHR.  

There are two excellent resources for certifying such staff. JCAHPO is now offering an ophthalmic scribe certification.  It will meet the CMS requirements for scribes. The press release may be found here. The exam includes 125 questions focused on History Taking, Ophthalmic Patient Services and Education, Ophthalmic Terminology, Medical Ethics and Legal Issues, and Medical Notes/Records. For less than $100 , staff may be certified for a 3 year period.

The other option to consider is the CMSS (Certified Medical & Surgical Scribe) certification offered by the American College of Medical & Surgical Scribes (www.theACMSS.org).

For more information on MU Stage 2, check out the article written by Darla Shewmaker and Jeff Grant for Ophthalmology Management. (Click Here )

 

Kimberly Baldwin, MA, LPC

Consultant, Designer, Solutions Expert