Wiki Physician vs. nurse documentation


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How will an EHR show the distinction between the data collected by a nurse and the data gathered by the provider? Currently, if the provider wants to include information from the nurse note, the provider has to state what was reviewed in the nurse note and indicate whether they concur or disagree - and their basis for doing so. Will an EHR make it more difficult to determine the codeable/billable elements of a patient visit? I work in primary care with multiple clinics. How will we know we are coding only the correct elements?
I'm no expert on EMR but I can say with our EMR ( Allscripts) there is an audit trail that we can view to know who documented what portions of the note. You may want to find out what EMR you'll be using in your clinic's and what type of "trail" you'll be able to find.

Currently when I'm auditing records 9 times out of 10 the "reason for visit" is the area the MA/nurse documents and the provider documents the cc and the History of present illness section. From time to time, I will find the the doc has documented in the reason for visit area and not the MA/nurse, then I can give credit for any information that is documented in that area when I am auditing the note.

I find ( in my experiences) that the MA/nurse documents very well in the reason for visit area, sometimes better than the HPI area that the physician is documenting. I get more info from the MA but I know I can't use it because it's documented by the MA/nurse.

Just my two cents on the EMR we have :)
I think it depends on your EMR. The one I used at my last job (NextGen) listed the nurse/MA note first with a signature and then the physician note started directly underneath it. Also, as Roxanne stated, the EMR leaves a great "trail" of who did what that you can always refer to. Good luck!

Hi, I have a question that maybe you can help me with. I am the only coder for a primary care facility. I have a couple of my doctors that are letting their nurses do the HPI. I have told them they cannot do this. I recently went back and asked one of my physicians to go back and sign off on it and the physician stated " it is signed with the office note". We work out of Allscripts EHR and at the end of the note the doctors signature is on there. My question is will that count or does the physician still need to go back and add a addedum signature to the HPI? I would appreciate any help. Thanks:)