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ED Coding and Reimbursement Alert

Reader Question:

Signing the Charts

Published on Thu Nov 01, 2001

Question: Is a chart valid if the final diagnosis was written by someone other that the examining physician? For example, could the nurse act as a scribe only for the diagnosis?

Indiana Subscriber  
Answer: Because the final diagnosis is sometimes not known in the ED, in such departments it is OK for the nurse to record the final diagnosis as long as the physician signs off on the chart. It would be best in all cases to check with the carrier in question and get its policy in writing.
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