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Authorship in EHR

  1. Default Authorship in EHR
    Clearnace Sale
    In the OP or IP setting, can a physician electronically sign a midlevel's completed note and become the author taking credit for the midlevel's documentation? This is for midlevels not contracted with commercial plans. The physician is the billing provider and documents a supervisory note stating he evaluated the patient and supervised

    Thanks for any help!!

  2. #2
    Columbia, MO
    IS he evaluating the patient on the same day as the midlevel?

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Yes, the physician sees the patient the same day, adds a supervisory note, cosigns the midlevel's note and becomes the author and "owns the note." The midlevel's name and signature are still at the bottom of the note.

  4. #4
    Columbia, MO
    If he is going to bill these under his number as a physician encounter then he must have his own encounter note, not just signing the midlevels note. When you say supervisory note I am not certain what that would entail. But he must make his own assessment note.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    No, the physician does not have his own note. Just the supervisory note, which states:

    I, as the attending physician, personally evaluated the patient and directly supervised both care and planning. Patient acuity, any physical findings, changes in clinical status and changes in clinical management noted in this report are based on my direct assessments.

    Sometimes, they may add another little note which is about two sentences long and might have an exam element or two. Or just some medical decision making elements.

    Would you feel this is sufficient?

    Thank you for your help!!!

  6. #6
    Columbia, MO
    Not according to the strict definition, just signing the note even with an addendum is not he same thing as the physician having his own note. IMO anyway. However some might say it OK.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default
    Thank you Debra. Yes, me and several of the other auditors would agree with you. I just wanted to verify with some more outside opinions as our organization is leading us otherwise. (Based on IS)

    Thank you again!

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