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authorship of chart entry

  1. #1
    Location
    Orange County
    Posts
    60
    Default authorship of chart entry
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    Hi everyone,
    My question is:
    In regards to the EMR and an office visit..... the MA rooms the patient, enters the chief complaint and documents vitals, but does not sign off on this entry. The MD does, however, authenticate the note. In a perfect world, I know that we want the author of the chart entry to sign, but is it non compliant if there is no signature by the MA/nurse for their portion of the documentation? I have heard both yes and no from other auditors and would love to hear others advice on this.
    Thank you!

  2. #2
    Location
    North Carolina
    Posts
    3,126
    Default Question...
    We have two EMR's (temporarily). The EMR that will become our permanent EMR does not, visibly, record the "author" of each entry; however, this particular EMR has an internal tracking system that allows one, such as myself, to view who recorded the information. Is it possible that this is your scenario?

  3. #3
    Location
    Orange County
    Posts
    60
    Smile
    Possibly. I have a meeting with our EMR team tomorrow and I will definitely ask that question. Thank you.

    In reviewing records from different EHR systems, I notice that some "authors" of entries do show on the records. Do you feel that as long as there is a tracking system to validate the author of the entry, that would be sufficient ?

  4. #4
    Location
    North Carolina
    Posts
    3,126
    Default
    Personally, yes. If your system is able to track exactly who enters the data, you should be fine. Our EMR is very detailed with the tracking information and leaves very little to question. I'm not exactly fond of this particular area of the program since it does require an extra step of review but at least I can read the information now.

  5. #5
    Location
    Orange County
    Posts
    60
    Default
    Thanks Rebecca! Your the best.

  6. #6
    Location
    North Carolina
    Posts
    3,126
    Default
    My pleasure and thank you! Good luck...

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