.there must be a notation supplementing or confirming the
information recorded by others
If it was documented by other staff, I would look to see if he added to it or wrote a statement such as "ROS positive for.."
See also the following
7. Providers are responsible for clearly identifying who performed each service documented within the note. When entering patient data into the medical record that the provider did not personally take or test, the provider must attribute the information to the person who did.
8. If the provider references a form within the record (e.g., review of system form), he/she must reference the form with sufficient detail to uniquely identify the source. Example: â€śFor review of systems see form dated 1/1/08.â€ť
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