Wiki EHR Documentation

[asphillips1226]

In an EHR if the medical assistant documents the problem list, medical history and medication list does the documentation have to be listed in the doctors name or can it be in the MA's name? Can the provider sign off on the chart as a whole or does he/she need overwrite the MA's signature in each section?

 

[FTessaBartels]

ROS and PFSH may be documented by ANYONE

ROS and Past medical, family and social history may be documented by anyone ... but there must be evidence that the physician reviewed this information at the current encounter.

History of present illness must be documented by the provider.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[asphillips1226]

Our system documents each section under the person who documented. It overwrites the signature of each section only if the provider makes a change in that section. The provider then signs off on the chart as a whole. Do you think this is sufficient or should the provider make notation that they reviewed ROS, Past medical, family and social history?