sparkles1077
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Hello fellow coding professionals,
So, got a client that uses the transcription/EMR combination. The HPI exam and MDM are dictated and then pulled into the note by the midlevel. The LPN completes the ROS and PFSH. The CODER (yikes) pulls the ICD codes into the assessment and plan. Each section generates a signature when someone touches the charts. The transcriptionist does type in the name of the MD at the bottom of the HPI and the MDM. However, with the coder's signature on top, it really looks like the coder wrote the note. Does anyone know of any references that speaks to the dangers of having nonclinicans access the EMR documentation? I typically see this limited to clinicians.
Also, for dictations, unless they are using dragon voice, I typically see the date of dictation and date of transcription along with initials by transcriptionist. Does anybody know where the dictations rules are? I have hunted and can not locate anything.
Thank you
So, got a client that uses the transcription/EMR combination. The HPI exam and MDM are dictated and then pulled into the note by the midlevel. The LPN completes the ROS and PFSH. The CODER (yikes) pulls the ICD codes into the assessment and plan. Each section generates a signature when someone touches the charts. The transcriptionist does type in the name of the MD at the bottom of the HPI and the MDM. However, with the coder's signature on top, it really looks like the coder wrote the note. Does anyone know of any references that speaks to the dangers of having nonclinicans access the EMR documentation? I typically see this limited to clinicians.
Also, for dictations, unless they are using dragon voice, I typically see the date of dictation and date of transcription along with initials by transcriptionist. Does anybody know where the dictations rules are? I have hunted and can not locate anything.
Thank you