TCLewis12
New
There is some debate at the facility where I am a coder as to whether info that appears in our EMR software's print preview that is not in the note itself counts as part of a note's documentation. (Provider name, date of service, duration of visit, diagnosis, location, etc.) It has been argued that if it appears when printing a note from the software, it's acceptable, but that info outside of the note can be edited/changed by people other than the author of the note. For that reason, I have countered that all that info really should be contained in the text of the note itself, as only the author can edit or change it. What is acceptable in this case? - Thanks in advance . . .