# Assistant surgeon dictating op note



## GIBBERS (Oct 27, 2011)

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Does anyone know what the medicare guidelines are for the following:

We have a couple of cardiac surgeons that do not like to dictate their op notes. Recently one of them has started having the assistant surgeon dictate the op note. And....the assistant surgeon is the one signing off on the op note. 

This does not look right to me. If the assistant surgeon does dictate the op note, should there be some kind of statement on the report stating that it was the assist surgeon dictating the report. I would think that it would still have to be the primary surgeon that signs off on the report.
If anyone has any imput on this i would be grateful. 

Is there anyplace i can go to get documentation on this issue?
Thanks to all.

Gibbers


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## ajs (Oct 27, 2011)

GIBBERS said:


> --------------------------------------------------------------------------------
> 
> Does anyone know what the medicare guidelines are for the following:
> 
> ...



www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf

This document covers all sorts of indication regarding physician signature in the medical record.  I believe that if the surgeon is BILLING for the surgery as primary surgeon, it is required that they at least SIGN the operative report.  If they have someone else dictate it, they must at least attest that the information in the report is accurate.  Many hospitals have a requirement that the primary surgeon dictates and signs their own operative reports, so check with the hospital contracting department.  The other entity that would be involved is the physician's malpractice insurance company.  They often times have guidance for providers on these issues.  If the surgeon does not sign their operative report they are opening up themselves to potential malpractice if something goes wrong!


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## GIBBERS (Oct 27, 2011)

Thank you, Arlene


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