Wiki MA documenting

[sundaey]

We are currently having a debate in our office regarding this topic. The MA can only document the CC and take vitals, right? Isn't the doctor supposed to document everything else regarding the pt? If so, where can I find it in "black and white"?

 

[member7]

Check under the CMS website for evaluation and management documentation guidelines. You should find in the guidelines what the ancillary staff can document and what the physician should document.

 

[RebeccaWoodward*]

http://www.cms.hhs.gov/MLNEDWebGuide/25_EMDOC.asp

I use '97 guidelines. Refer to page 6. ROS and PFSH can be recorded by ancillary staff. The provider needs to document that he reviewed the information.