Wiki Dictation & patient visit form

[bkwrmz7]

If you have a pt visit form that the ma writes in the vitals & cc, does the dr still need to write all the notes of the visit or can he just dictate them and that serves as the visit notes? I'm confused.

 

[Walker22]

The doctor is the one that must document the chief complaint. The MA can't do it.

 

[FTessaBartels]

Physician documentation

The physician may hand write his/her notes, may dictate or may do a combination. Doesn't matter. What matters is what the physician documents s/he performed by whatever means.

Hope that helps.

F Tessa Bartels, CPC, CEMC