Wiki DOS on each page question

Create Wiki
T

tammyp74

New
Messages
4
Location
Franklin, Tennessee
Best answers
0
Does anybody know if the DOS is required to be on all pages of an encounter? If the dictation is more than one page, aside from the patient's name, does the DOS have to be there? I also need documented proof of this. I have looked on the AAPC website, AHIMA website, CMS, and several others and could not find anything that states that the DOS is required on all pages.
Thanks for your help!
 
I haven't looked

I haven't looked ... our dictation/transcription system keeps each document in its own folder, so we'd never have them mixed to begin with. But if the date isn't on each page I suppose they could get mixed up when printed....

I'll have to look ...

OKAY .. our system uses a unique "visit number" for each encounter. The patient name, Med rec #, date of birth, and visit number repeat in a "label" at the top of each page when printed (this repeats in a banner across the bottom of each page as well) . The actual date of service does NOT repeat on each page.

F Tessa Bartels, CPC, CEMC
 
Last edited:
Are you talking about an electronic medical record that you may need to print or are you talking about a traditional paper chart?
 
Paper Charts

Re our hospital paper charts ... we TRY to get residents / doctors / nurses / social workers / etc to add the date (and "continued") if they have to continue a note on the next page. We're not always successful. In our system, a hospital inpatient stay will have the SAME visit number for the entire stay (even the kid who stayed for 333 days had only ONE visit number).

Regardless, I'm not aware of having any payment issues as a result.

Can you tell us why you're asking? What's at issue?

F Tessa Bartels, CPC, CEMC
 
We had an auditor that came into our agency for a licensure audit and we were told that we had to have the patient name, medical record #, and a page number on each page of the note. We were told it was was for legal reasons so that there would not be a question about missing documentation.
I hope this helps!
 
pt documentation

In our office we always have a pt name and DOS on each page! Even if its a 2-sided sheet. When copying records, if they get mixed up, we do find pages that are out of order. Also, anything in a pt's chart is a legal document. If a chart is audited, or is copied for legal purposes, all pages/forms/notes must be able to tell the reader who the pt is, and on what date he was there.
 
You must log in or register to reply here.
Top