fgreen776
New
Can the RNs contribute to the documentation of a billable EM visit in an office setting with physician being present?
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Wiki Registered Nurse EM Documentation
- Thread starter fgreen776
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- registered nurse
mitchellde
True Blue
An RN may not document any part of the E&M note to be counted as part of the visit level. The RN can collect the ROS which must then be documented by the provider as reviewed with the patient and noting pertinent positives and negatives.
Your RN could document, but as a scribe only. It must clearly be stated in the record that she is acting only as a scribe and the physician must sign the attestation. You need to tread carefully when using clinical staff as scribes because they are not permitted to interpret/interject/etc. They may only simply type what the physician stated. I would not recommend it, but it is certainly possible if they have been properly trained and it is clearly documented.