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. Interested in becoming a medical scribe, inquire with CAAHEP.org/MSSRB
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, Local and The Joint Commission 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). Graduates select, following purchase, from General or Specialty-specific exams, including ophthalmology, emergency medicine, dermatology, vascular, or urgent care.
Those students who successfully pass MSCAT and do not have 200 hours of clinical employment experience, will be a Certified Medical Scribe Appretice (CMSA). Once hours are fulfilled, full recognition of CMSS will be awarded. Of note, those individuals possessing a certification or licensure of Practical Nurse, Registered Nurse, Paramedic or Certified/Registered Medical Assistant will be awarded CMSS upon successfully completing 50 hours of clinical instruction experience.
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.
ACMSS is a Sponsoring Organization for Academic Accreditation with Commission on Accreditation of Allied Health Education Programs (CAAHEP).
ACMSS encorses the CAAHEP Standards and Guidelines for the Accreditation of Educational Programs for the Medical Scribe Specialist (MSS).