In my office there are different thoughts on the use of the rounding nurse (RN) documentation being used for billing physician services. The provider does render face-to-face with the patient.The dictated H&P is done by the provider but when I review the charts the hand written H&P is documented by the rounding nurse, it does not indicate that the rounding nurse is noting/scribing for the physician. This is also the case with written progress notes. I have instructed my physicians and administration of the E&M guidelines that indicate the HPI, Exam and A/P must be done by the physician.

We have the bylaws from the hospital facility which indicate:
- Rounds and medical record entries by the rounding nurse SHALL NOT be substituted for the physician(s) rounds or medical record entries
- The rounding nurse MAY NOT ADMIT. The admission notes is the full responsibility of the physician and MAY NOT be made by or on the order of the rounding nurse.

I have been asked if this process is within the legal guidelines and do I have documentation stating this is inappropriate. I am not able to find anything regarding the use of rounding nurse documentation, can any help me support what I believe to be correct and that the rounding nurse documentation should not be used for physician billing?

Thank you in advance for your help...