The American College of Medical Scribe Specialists governing body has voted in 2010 and agreed upon the following requirements so it ensures that the candidate, or academic program, adequately understands the role of a Certified Medical Scribe Specialist (CMSS), can function in a highly demanding environment, and ensure that those individuals who receive certification are competent in their respective field and compliant with all mandates and policies. CMS recognizes Certified Medical Scribe Specialists (CMSS) in meeting Meaningful Use/MACRA regulations of the Personnel Measure in ” who may document in CEHRT.
1. Pre-clinical training that includes:
- Medical Terminology
- Basic Anatomy
- CMS Core Measures
- Basics of Coding
- Documentation for Billing and Medical Legal Liability
- HIPAA Compliance
- Functions of Hospital or Clinic Electronic Data Information Source
- Basics of History and Physical documentation
- Clinical scenarios
- EMR training. Adhering to TJC, CMS, and MU criteria
2. Clinical training that includes:
Clinical instruction would be defined as training as a medical scribe in a patient care area. If a patient care area is not available, then the scribe could still be considered as having received clinical instruction if the training closely simulates scribing in a patient care area. Simulation would need to include:
- 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 disposition
- 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 (i.e., telemetry, ultrasound machine, vacutainer, O2 sat, sphygmomanometer, syringe, BP cuff, nasal cannula, yankauer suction, 12-lead EKG, plain film X-ray, CT scan, MRI)
- Dispositions which include Admissions, Discharge, and Transfers (ADT)
3. Passing the board examination with a pass rate of 80 percent or higher
Certification examination contains 100 questions based on medical terminology, HIPAA, medicolegal risk mitigation, visit-level assignments, knowledge of computer skills and function of an electronic health record. All topics are covered in pre-clinical and clinical training. Exam consists of multiple choice, multiple-multiple, true-false, and fill-in questions.
In order to sit for the MSCAT credential and certification exam, the scribe must have successfully completed 200 hours of clinical instruction. However, those individuals with a license or certification of Registered Nurse/Practical Nurse, Paramedic, Certified/Registered Medical Assistant will be allowed to sit for the exam with 50 hours of clinical instruction.