BS&SC
Networker
I am pretty sure I know the answer to this, but I constantly doubt myself when I can't find some resource to back me up.
1) Can one provider document for another because "it was a busy night." Separate from that, I have another problem with a provider doing a 3rd degree laceration bedside, but there is no procedure note on it, just the CNM's documentation that it was done... Is this a query-the-provider situation for both? If so, (question #2)
2) Are there any good online resources for proper documentation pertaining to OBGYN that I can reference when querying the providers?
3) Is there an audit tool for MDM specific to OBGYN? I know there is the H&E audit tool, but would love to see one for MDM.
1) Can one provider document for another because "it was a busy night." Separate from that, I have another problem with a provider doing a 3rd degree laceration bedside, but there is no procedure note on it, just the CNM's documentation that it was done... Is this a query-the-provider situation for both? If so, (question #2)
2) Are there any good online resources for proper documentation pertaining to OBGYN that I can reference when querying the providers?
3) Is there an audit tool for MDM specific to OBGYN? I know there is the H&E audit tool, but would love to see one for MDM.
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