# Hospital Rounding Nurse Documentation



## SScott10315 (May 22, 2009)

In my office there are different thoughts on the use of the rounding nurse (RN) documentation being used for billing physician services. The provider does render face-to-face with the patient.The dictated H&P is done by the provider but when I review the charts the hand written H&P is documented by the rounding nurse, it does not indicate that the rounding nurse is noting/scribing for the physician. This is also the case with written progress notes. I have instructed my physicians and administration of the E&M guidelines that indicate the HPI, Exam and A/P must be done by the physician.

We have the bylaws from the hospital facility which indicate:
- Rounds and medical record entries by the rounding nurse SHALL NOT be substituted for the physician(s) rounds or medical record entries
- The rounding nurse MAY NOT ADMIT. The admission notes is the full responsibility of the physician and MAY NOT be made by or on the order of the rounding nurse.

I have been asked if this process is within the legal guidelines and do I have documentation stating this is inappropriate. I am not able to find anything regarding the use of rounding nurse documentation, can any help me support what I believe to be correct and that the rounding nurse documentation should not be used for physician billing?

Thank you in advance for your help...


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