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Nurse vs MD EMR documentation in an audit

  1. Default Nurse vs MD EMR documentation in an audit
    Medical Coding Books
    The question has come up during on of our EMR compliance work sessions as to whether from an auditing standpoint, does the physician have to authiticate each section of the EMR or is the authintication at the end of the note sufficient?

    For instance in our EMR set up, a patient comes in the office and the nurse/med assist. takes vitals, obtains medication information, allergies and that type of information and the EMR populates the nurse/med assist. name in that section of the record. However, the physician does not come back in and authinticate those sections, but does authinticate the note at the end. Does the physician get credit in an audit for those sections?

    Any supporting documentation would be appreciated

    Thank you

  2. #2
    Default
    Quote Originally Posted by twtcpc View Post
    The question has come up during on of our EMR compliance work sessions as to whether from an auditing standpoint, does the physician have to authiticate each section of the EMR or is the authintication at the end of the note sufficient?

    For instance in our EMR set up, a patient comes in the office and the nurse/med assist. takes vitals, obtains medication information, allergies and that type of information and the EMR populates the nurse/med assist. name in that section of the record. However, the physician does not come back in and authinticate those sections, but does authinticate the note at the end. Does the physician get credit in an audit for those sections?

    Any supporting documentation would be appreciated

    Thank you
    This is the policy from our teaching hospital - it's pretty in-line with Trailblazer Medicare in Texas. The doctor must document his own HPI and exam (Except VS measurements), but there are some other rules, too - Maybe you can get some suggestions, here, though: http://www.ttuhsc.edu/billingcomplia...book_12_10.pdf
    Last edited by btadlock1; 03-22-2011 at 07:30 PM.

  3. Default
    Thank you

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