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Wiki Observation e/m

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laurabullard

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Local Chapter Officer
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Location
Flatwoods, WV
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I was wandering, our Surgeon's nurse (who is qualified) saw a pt. and the done the H&P (short form, hand written). All our Surgeon did was sign at the bottom. My question is does he not have to document that he approves with findings, or is it ok for just the signature? We are a Critical Asses Hospital

thank you for any help given.

Laura Bullard, CPC
 
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