mrolf
Guest
Auditing E/M's for a physician. In his clinic dictation patient comes in with a sinus infection.
The physician states he puts the patient on an antibiotic but does not state the name of the antibiotic, dosage or directions. I realize that it should be documented, because it is part of good patient care. However, before I confront the physiican are there any regulations to the effect that state the name etc must be documented. This has happened several times lately. Would like to have my ducks in a row before approaching the physician. Can be kind of prickly sometimes. Any advice would be helpful. Thanks
The physician states he puts the patient on an antibiotic but does not state the name of the antibiotic, dosage or directions. I realize that it should be documented, because it is part of good patient care. However, before I confront the physiican are there any regulations to the effect that state the name etc must be documented. This has happened several times lately. Would like to have my ducks in a row before approaching the physician. Can be kind of prickly sometimes. Any advice would be helpful. Thanks