Who can input/alter medical records in the chart?

[MSACKETTPRL]

Is there anything official out there that says clinical staff must be the ones to enter/alter immunizations/injections into the medical record (EMR)? For example, an RN gave an immunization or injection and used the wrong CPT code but everything else was correct in the immunization record, can a nonclinical staff member remove/ add the correct information into the medical record?

 

[YLG74]

Reply to Who can document in the medical chart

I would suggest review your local FI carrier.
for example WPS and other administrators state.....

A 1. 1995 and 1997 Documentation Guidelines (DG) do not address who can record the chief complaint. WPS Medicare will allow the CC when recorded by ancillary staff. However, the physician must validate the CC in the documentation. The 1995 and the 1997 Documentation guidelines indicate ancillary staff may obtain the ROS and PFSH but they do not indicate the ancillary staff can obtain the History of Present illness.

Hope this helps.

 

[ndebien]

Is it just the CPT that was incorrect? CPT shoudn't be included in the medical chart either way... financials are supposed to separate from clinic