RebeccaWoodward*
True Blue
I think we have established, in previous threads, that the chief complaint must be documented by the physician. For those of you already on an EMR system, what is your protocol for nurses/cma's taking the CC? Do you have your physician restate the CC or does your physician insert his/her name below the nurse/cma name (an indication that he has personally asked the patient and agrees with the nurse/cma's entry)?
Our EMR system has a "audit trail"; however, if the physician doesn't somehow, somewhere, notate the CC...how can we (I) prove that we are compliant?
I've presented this question to other auditors, educators...and we seem to agree what needs to be said and documented, but if anyone has any personal experience, I would love to hear it!
Our EMR system has a "audit trail"; however, if the physician doesn't somehow, somewhere, notate the CC...how can we (I) prove that we are compliant?
I've presented this question to other auditors, educators...and we seem to agree what needs to be said and documented, but if anyone has any personal experience, I would love to hear it!
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