Pre-populating visit notes before the patient is seen

dparham

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I work for a one doctor primary care office. We have 3 CMAs. Two of them are populating the visit notes for the day's visits with all of the information, including the exam, assessment and treatment. I am saying that at least the exam and treatment must be done when the patient arrives and in the room with doctor. One of them can do this as a scribe for doctor which would help him with everything that needs to be addressed at that visit. They can then put in the information doctor addressed in the visit. But they are saying that doctor will make the changes to what they have in the visit note if he changes them or will add anything he finds he needs to. Sometimes I don't see this happens but if he said he did it and sign off, its probably okay. I see a lot of this cloning with specialists to as it saves them time. Does anyone have any information on this scenario. My email is medss@comcast.net if anyone can email me.

The MA who works from home also adds to the assessment the following two codes in the Assessment: I believe this codes are for the labs or imaging places to use when they do these tests. Am I correct? I don't want to say anything unless I am sure.

19. Encounter for screening mammogram for malignant neoplasm of breast - Z12.31
20. Colon cancer screening - Z12.11
 

eberra

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This is a compliance issue. Your CMA's should not pre-populate the exam and assessment. They cannot know what the physician/practitioner may decide to exam prior to the actual visit. Your CMA's can enter the history and any portions of the exam they perform. The physician/practitioner should document/dictate his/her exam and medical decision-making for the patient.
 

csperoni

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This just has a bunch of red flags. While the MA may certainly scribe for the clinician, they can't do it BEFORE the patient is seen. Other than history (and then make any necessary updates during the visit), I don't see how this can be done prior.
 
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