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Your Documentation Responsibility

What Scribe can do, what only you can do, and why it matters for OASIS-E2.

Is Scribe's draft the official medical record?

No. Scribe produces a draft — review and edit every entry before you sign. The signed entry, not the draft, is the legal medical record.

What does signing actually mean?

Your signature is your attestation that the record is true and complete. Responsibility for accuracy can't be delegated to the tool — you are the author of record.

What can AI do under OASIS-E2 (effective April 1, 2026)?

CMS's OASIS-E2 Final Guidance Manual allows AI to review the visit, run quality checks, and recommend a suggested OASIS response to speed you up. It's a starting point, not the final word.

What must I do myself?

Review every recommended response, correct anything that's wrong, and enter the final OASIS answer yourself. The determination is yours on every item.

What happens if my documentation is audited?

In an audit (TPE, ADR, RAC, UPIC, or a state survey), you — not the AI — have to defend the record. Reviewers look for evidence that you, the assessing clinician, determined each response, so your review, entry, and signature need to be documented for every item.

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