myeo
Networker
Hi everyone,
My question is:
In regards to the EMR and an office visit..... the MA rooms the patient, enters the chief complaint and documents vitals, but does not sign off on this entry. The MD does, however, authenticate the note. In a perfect world, I know that we want the author of the chart entry to sign, but is it non compliant if there is no signature by the MA/nurse for their portion of the documentation? I have heard both yes and no from other auditors and would love to hear others advice on this.
Thank you!
My question is:
In regards to the EMR and an office visit..... the MA rooms the patient, enters the chief complaint and documents vitals, but does not sign off on this entry. The MD does, however, authenticate the note. In a perfect world, I know that we want the author of the chart entry to sign, but is it non compliant if there is no signature by the MA/nurse for their portion of the documentation? I have heard both yes and no from other auditors and would love to hear others advice on this.
Thank you!