Is it OK for office staff to document?

Orthocoderpgu

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I have an office manager that is a go-getter. The problem: I think that she is documenting things that she should not be documenting. For example: Doc forgets to document the cheif complaint and the office manager does it and does it without speaking to the physician involved. Something tells me that this is wrong or at least, not right. Toughts?
 

mitchellde

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I have an office manager that is a go-getter. The problem: I think that she is documenting things that she should not be documenting. For example: Doc forgets to document the cheif complaint and the office manager does it and does it without speaking to the physician involved. Something tells me that this is wrong or at least, not right. Toughts?
No this is not allowed. The chief complaint must be documented by the provider. Look at your documentation guidelines. It tells you only the ROS may be documented by qualified ancillary personnel. The office manager is not in this category. And this not the ROS u are referring to. She was not present for the encounter and has no idea what wad discussed
 

Mojo

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You are correct, qcoder. She should not be altering the medical record. Ancillary staff may only document ROS, PFSH and findings. Documentation by ancillary staff requires an attestation by the provider that he has reviewed it for accuracy when it is used for coding the E/M.

Keep the prescription pad away from her. jk
 
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