Wiki *HELP* with documentation guidelines

[peanutbutterkisses]

Am I correct, that in order to count ROS and PFSH from nurses notes the Dr. needs to a note ststing he has reviewd the nurses notes. If it is an electronic note does that still apply if the Dr. has to close the chart. Would that count as an acknowledgement of review?

Thank you

 

[FTessaBartels]

Attestation Statement

We are in a teaching facility so we are very strict about attestation statements. The physician MUST positively attest to having reviewed and agree with documentation recorded by someone else, whether that is the nurse, a resident, the patient (on the questionaire) or another teaching physician. If it is not posivitely attested to, we don't count it. No arguments. It is our policy and our Compliance Dept holds our teaching physicians's feet to the fire on this issue.

Incidentally, with an EMR it should be fairly easy to include a macro for the attestation statement that won't require much more than a click to be added to the record before the physician signs off.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[peanutbutterkisses]

Great, Thanks so much.