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Guidelines for the Use of Scribes in Medical Record Documentation
WPS Medicare Part B, WPS Medicare Part B (Medicare Administrative Contractor), hosted by the American College of Emergency Physicians, 2009
Read the originalRead on October 16, 2026
- What it is
- A Medicare Part B contractor's guideline on physicians who use a scribe to document visits. It says the scribe documents the physician's dictation and activities during the visit, and that the physician co-signs the note as an accurate record.
- How much weight it carries
- Written by a Medicare Administrative Contractor and so reflects the Medicare view of evaluation and management billing. It is an older guideline, dated by its web address to 2009, and it does not cover AI scribes. Check the current contractor and CMS rules before relying on it.
Facts taken from this source
- Under the WPS guideline, the physician co-signs a scribed note to indicate that it is an accurate record of both the physician's words and actions during the visit.
“Physician co-signs the note indicating the note is an accurate record of both his/her words and actions during that visit” (Guidelines for the Use of Scribes in Medical Record Documentation, list of requirements for physicians)
- Medicare's WPS guideline says that in evaluation and management services, a scribe does not act independently and simply documents the physician's dictation and activities during the visit.
“does not act independently, but simply documents the physician's dictation and/or activities during the visit” (Guidelines for the Use of Scribes in Medical Record Documentation, opening section)