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DOS on each page question

  1. Default DOS on each page question
    Medical Coding Books
    Does anybody know if the DOS is required to be on all pages of an encounter? If the dictation is more than one page, aside from the patient's name, does the DOS have to be there? I also need documented proof of this. I have looked on the AAPC website, AHIMA website, CMS, and several others and could not find anything that states that the DOS is required on all pages.
    Thanks for your help!

  2. #2
    Milwaukee WI
    Default I haven't looked
    I haven't looked ... our dictation/transcription system keeps each document in its own folder, so we'd never have them mixed to begin with. But if the date isn't on each page I suppose they could get mixed up when printed....

    I'll have to look ...

    OKAY .. our system uses a unique "visit number" for each encounter. The patient name, Med rec #, date of birth, and visit number repeat in a "label" at the top of each page when printed (this repeats in a banner across the bottom of each page as well) . The actual date of service does NOT repeat on each page.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 02-17-2009 at 01:54 PM.

  3. Default
    Are you talking about an electronic medical record that you may need to print or are you talking about a traditional paper chart?

  4. Default
    I am talking about both, paper charts and EMR. Thanks!

  5. #5
    Milwaukee WI
    Default Paper Charts
    Re our hospital paper charts ... we TRY to get residents / doctors / nurses / social workers / etc to add the date (and "continued") if they have to continue a note on the next page. We're not always successful. In our system, a hospital inpatient stay will have the SAME visit number for the entire stay (even the kid who stayed for 333 days had only ONE visit number).

    Regardless, I'm not aware of having any payment issues as a result.

    Can you tell us why you're asking? What's at issue?

    F Tessa Bartels, CPC, CEMC

  6. Default
    We had an auditor that came into our agency for a licensure audit and we were told that we had to have the patient name, medical record #, and a page number on each page of the note. We were told it was was for legal reasons so that there would not be a question about missing documentation.
    I hope this helps!

  7. #7
    Stratford, NJ
    Talking pt documentation
    In our office we always have a pt name and DOS on each page! Even if its a 2-sided sheet. When copying records, if they get mixed up, we do find pages that are out of order. Also, anything in a pt's chart is a legal document. If a chart is audited, or is copied for legal purposes, all pages/forms/notes must be able to tell the reader who the pt is, and on what date he was there.

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