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Dictation & patient visit form

  1. #1
    Angry Dictation & patient visit form
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    If you have a pt visit form that the ma writes in the vitals & cc, does the dr still need to write all the notes of the visit or can he just dictate them and that serves as the visit notes? I'm confused.

  2. #2
    Default
    The doctor is the one that must document the chief complaint. The MA can't do it.
    Walker Bachman, CPC, CPPM

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Physician documentation
    The physician may hand write his/her notes, may dictate or may do a combination. Doesn't matter. What matters is what the physician documents s/he performed by whatever means.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 02-26-2010 at 12:00 PM.

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