Documentation requirements for performing provider of a procedure


Monson, MA
Best answers
If an ER physician see's a patient and does a procedure while the patient is in the ER and documents a separate procedure note, does the procedure note need to clearly indicate who the performing provider is, or is the signature of the entire note enough..
I see that within the note they are referencing the procedure done and indicating to look at the separate procedure note. The MD is stating that the ER physician who see's the patient is always the one who does the procedure but i just want to be clear if the procedure note itself should indicate who the performing provider is?
Thank you
Ruth Mooney, CPC, CPMA


True Blue
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All notes need to be authenticated by the performing and documenting provider. I'm not completely clear what you're seeing on this note though - is the evaluation note signed but the procedure note is not signed? If your providers are using an EHR, the procedure note must have an audit trail indicating who did the documentation - it may not necessarily be visible in the printed record but would need to have been authenticated before the record could have been closed. If it's a paper record, the procedure note should be signed legibly to identify the provider.