In 2010, American College of Medical Scribe Specialists governing body voted and agreed upon the following requirements to ensure the candidate, or academic program, adequately understands the role of Certified Medical Scribe Specialist. (CMSS) The CMSS can function in a highly demanding environment and ensures those individuals who receive certification are competent in their respective field, compliant with all mandates and policies. Programs may accredit the Medical Scribe Specialist programmatic pathway through CAAHEP.org/MSSRB.
It is recommended that programs interested in becoming CAAHEP accredited review the Standards of the Medical Scribe Specialist Profession (https://www.caahep.org/CAAHEP/media/CAAHEP-Documents/MedicalScribeSpecialistStandard.pdf). If you feel your program meets the CAAHEP Standards, programs interested in seeking CAAHEP accreditation are being directed to: http://ras.caahep.org/.
1. Pre-clinical training includes
- Medical Terminology
- Basic Anatomy
- Centers for Medicare and Medicaid Core Measures
- Basics of Coding and Billing
- Documentation and Medical Legal Liability
- HIPAA Compliance
- Functions of Hospital or Clinic Electronic Data Information Source
- Basics of History and Physical documentation
- Clinical scenarios in the medical sub-specialities
- Electronic Health Record (EHR) training
- Adhering to Federal, State, and Local laws, governance, and standards
- Meaningful Use
2. Clinical training that includes
- Correctly documenting into an EHR
- Correctly documenting orally provided history and physical exams
- Awareness of medical test results ie calling the appropriate department if results not received in 1 hour, documenting the labs correctly into the patient medical record
- Correctly documenting dispositions, admissions, and transfers (ADT)
- Awareness of the provider’s patient case load
- Awareness of ancillary staff present, their job titles and duties
- Demonstration of ability to correctly sign their case load out
- Demonstration of how to correctly document the attestation requirement per the Joint Commission
- Awareness of CMS regulation that , within the hospital, scribes are not allowed to enter orders
- Demonstration of how to log in and log out.
- Demonstration of how to quickly obtain phone numbers for ancillary departments ie radiology, pharmacy, cafeteria, laboratory.
- Demonstration of how to recognize a HIPAA violation and how to appropriately share Protected Health Information
- Demonstration of what is considered a HITECH violation
- Ability to document and keep track of at least 3 active patient cases, their position in the patient encounter process (ie from patient registration to dispo)
- Correctly identify common 50 medical devices, including but not limited to, telemetry, ultrasound machine, vacutainer, O2 sat, Sphygmomanometer,syringe, BP cuff, nasal cannula, Yankauer suction, 12-lead EKG, plain film x-ray, CT scan, MRI.
- Clinical scenarios
- Patient Encounters – minimum 200 unassisted documented clinician-scribe encounters
Upon graduation, all students may sit for the Medical Scribe Certification & Aptitude Test (MSCAT).
3. Passing the board examination with a pass rate of 80 percent or higher
Certification examination is 2 hours and prepares the individual for being a proficient and highly engaging Certified Medical Scribe Specialist (CMSS) to directly clinically assist clinicians at the point of care with the complexities needed to handle the demands of clinical documentation requirements. Exam core competencies include, but are not limited to, clinical workflow scenarios, application and workflow of delivering succinct medical care to patients at the time of the visit, HIPAA for Medical Scribe Specialists, medicolegal risk mitigation, visit-level assignments, highly functioning and proficient computer literacy and skills, core functions of Certified Electronic Health Records Technology (CEHRT). All topics are covered in pre-clinical and clinical training. Exam consists of multiple choice, multiple-multiple, true-false, and fill-in questions.
ACMSS is the Sponsoring Organization for Academic Accreditation with Commission on Accreditation of Allied Health Education Programs (CAAHEP).
ACMSS sponsors the CAAHEP MSSRB standards and guidelines toward programs offering an accredited medical scribe specialists program.