Wiki entering data in progress note before visit

[arizona1]

I recall reading that data cannot be entered in an office note/progress note prior to patient's face-to-face visit. It was said this is because if the visit was cancelled, this entry would be regarded as fraud.

I have searched and cannot find a reference to support this guideline.

Any help would be greatly appreciated.

Thank you

 

[mitchellde]

I recall reading that data cannot be entered in an office note/progress note prior to patient's face-to-face visit. It was said this is because if the visit was cancelled, this entry would be regarded as fraud.

I have searched and cannot find a reference to support this guideline.

Any help would be greatly appreciated.

Thank you

How can anything be entered into a progress note prior to the actual encounter? Everything must be verified with the patient by the provider. The only information that can be pulled from a previous note is the ROS and that must be updated and reviewed with the patient. So what is it the you are wanting to pre document?

 

[teresabug]

I recently worked in an office where one of the drs would create a note in the EHR the day before. Scary stuff. I think this happens more than people realize. So to answer your question I don't know either. Just glad I don't work for him anymore.

 

[arizona1]

Thank you for your replies. I agree with both of you and was told I was incorrect. I know I read something that specifically stated this cannot be done and wanted to find it to show a co-worker. Thank you.

 

[msonger]

data entry of history

Our EMR has data tables for each history type, ROS, Exam, etc. Would it be permissible for a medical assistant to load historical data (history only) obtained from a patient questionnaire or another physician record prior to the OV to help improve the amount of time spent reviewing the actual data in the system with the patient at the time of the visit before giving to the provider to review and update and elaborate as needed?