Providers who chart after hours are not slow; they are doing two jobs. Our virtual medical scribe services take the documentation off the provider's plate: a trained remote scribe follows the visit, live or from a recording, and builds the note in your EHR so the provider spends the visit with the patient and signs a finished note the same day.
What our medical scribe services include
Each provider gets an assigned scribe who learns their templates, their exam style and the way they like the assessment written. The scribe drafts the history of present illness, review of systems, exam and assessment and plan, queues the orders, referrals and follow-up the provider called out, and leaves the note ready for review. A trained backup covers absences, working from the same written provider profile, so the note looks the same whoever drafted it. Scribes do not make clinical decisions, and nothing is final until the provider signs.
Live scribing or recorded visits
Live scribing connects the scribe to the exam room through a secure audio link, and the note is finished as the visit ends. It suits clinic days with steady volume. Recorded visits use an approved recording app, and the scribe completes the note within hours. That suits providers with variable schedules, procedure days or rooms with unreliable connectivity. Many practices mix the two, and either way the scribe works in your EHR, not in a separate system that has to be copied across.
Documentation that supports the code billed
A note written for the visit is also the evidence for the claim. Office visits are leveled by medical decision making or by total time, and the difference between 99213 and 99214 is what the note shows about the problems addressed, the data reviewed and the risk of management. Scribes are trained to document those elements as the provider states them, to record total time when the provider bills by time, and to capture the separate problem that supports modifier 25 when a procedure and a visit happen together. Where the provider follows up on a serious or complex condition over time, the note shows the ongoing relationship that G2211 depends on. Our medical coding team can review scribed notes against the codes billed, so documentation gaps surface as feedback rather than as a CO-16 or a payer audit.
Compliance and access
Scribes work under a signed business associate agreement, through your remote access, with an EHR login you issue and can revoke. Access is limited to the charts on the provider's schedule. How long a recording is kept, and when it is deleted, is written into the agreement before the first visit is recorded. Under the Medicare Program Integrity Manual, CMS does not require the scribe to sign the entries they make, but the provider must review and sign the note, and your EHR audit trail should show both. Where the EHR offers a scribe role or attribution field, we use it.
Starting with one provider
Most practices start with the provider who is furthest behind on charts. The scribe spends the first week learning the templates and the provider's preferences, then documents with every note reviewed, and the provider profile is corrected as patterns appear. Once the notes need few edits, the provider moves to light review and the practice decides whether to add more providers. Practices that also need help at the front desk can pair scribing with a virtual medical assistant for scheduling and insurance work.
Pricing
Scribing is priced per provider by the hours or clinic sessions covered each week, with live and recorded scribing quoted separately. There is no percentage of collections and no long-term commitment beyond the notice period. See pricing for the current structure or contact us to scope scribing for your providers.
What Is Included
- Live remote scribing or documentation from recorded visits
- HPI, exam, assessment and plan drafted in your EHR templates
- Orders, referrals and follow-up queued for provider sign-off
- Notes ready for review and signature the same day
- One assigned scribe per provider, with a trained backup
- Signed BAA, your EHR logins, access limited to the role
| Scribe documentation | CMS does not require a scribe to sign or date entries they make for a provider; the treating provider signature affirms the note documents the care givenSource: CMS, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 |
|---|---|
| Business associate agreement | A scribe service that receives or records protected health information for a practice is a business associate and needs a written contract before work startsSource: HHS, Business Associates |
Virtual Medical Scribe Services: Common Questions
A virtual medical scribe listens to the visit, live through a secure connection or from a recording, and documents it in your EHR: history, exam findings, assessment and plan, and the orders the provider calls out. The provider reviews, edits and signs the note. The scribe does not make clinical decisions or enter orders on their own authority.
No. Under the Medicare Program Integrity Manual, CMS does not require scribes to sign or date the entries they make. What matters is that the treating provider reviews the note and signs it, because that signature is the provider affirming that the documentation reflects the care given.
Live scribing suits providers who want the note finished as the visit ends and are comfortable with a scribe on a secure audio connection. Recorded visits suit providers with variable schedules or poor connectivity, and notes are completed within hours. Many practices use live scribing for clinic days and recordings for procedures.
Each scribe is trained on the provider templates, phrasing and exam style before going live, and the first weeks of notes are reviewed with the provider. Recurring corrections are written into the provider profile, so the backup scribe documents the same way as the primary.
Scribes work in the EHR you already use, through remote access and a login you issue. Nothing is copied to our systems. If your EHR has a dedicated scribe role or note attribution, we use it, so your audit trail shows who drafted the note and who signed it.