Wiki Help with documentation by non-medical person on a medical visit

[Barbiejean]

We've got 2 MA/LVN people in our office that scribe for our physician. Our front desk person has started to take vitals (weight, temp, BP/pulse) as well as ask for CC from the patient. When I've gone back thru to audit the records, I"m seeing 2 sometimes 3 different handwriting styles but only 1 or 2 initials. Can our front desk person do the vitals and not initial or if she initials what she does is it okay. I can't find any documentation to support or disprove it, but my gut tells me NO. She has no medical training at all and I don't want to put our practice in jeopardy just because she's trying to "help" move the patients thru the office. Thanks for any advice.....

 

[emcee101]

I know patient wait time is important and we all try to keep it to a minimum, but an untrained staff member taking vitals and documenting clinical information would not be worth the risk of inaccuracies and the 2 minutes that it would save your trained staff. I would restrict all clinical services and documentation to your trained medical staff. This way you reduce your risk an optmize the acuracy of the information in your charts. Have them do the job they were hired, educated and trained to do.

Also, anyone who documents anything in a medical record should be initialing their work with a signature log in place so you can always identify who did what. They should also include any credentials with this as well.