Wiki Rounding Nurse documentation

[jazzyblues2005]

We have a scenario where an R.N. is rounding and assessing a physician's patients. She is documenting a progress note that includes an exam and hpi and signs it with her signature that includes "plan per Dr. X". The only documentation from the physician is a section at the bottom of the note with updates to medications, etc. I know a PA or NP can do this, but am unsure that an RN can provide these services.

Does anyone have similar situations or have any documentation supporting or contradicting this?

Any information would be appreciated.

Thanks!

 

[mitchellde]

No an RN cannot provide this service and it definitely cannot be billed out. You can look under RN scope of service rules. Or check with your nearest nursing program. Nurses must work under direct physician supervision when employed in a physician office setting. And they can never be the one to see the patient and provide the documentation when the physician is off site.

 

[OCD_coder]

Debra is 100% correct. The only information the RN can record and collect are the ROS and PFSH components and this even requires an attestation by the physician.

This is per the 1995 Documentation Guidelines.