# Coding from Nursing Documentation?



## WilsonGA2 (Apr 18, 2011)

I did not think it was okay to code a medical diagnosis from nursing documentation. I thought it had to be from the physician's notes or report. I am struggling with a coder who is coding diagnoses from nursing documentation and I am being graded by this coder to go onto my next step as a coder. I strongly believe I should not be learning to do this wrong, and especially doing it wrong just to pass onto my next step as a coder. Does anyone have professional documentation from a trusted source that I can reference to to support that it is not okay to code from nursing documentation and that it needs to be from physician documentation?


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## OCD_coder (Apr 18, 2011)

If the physician documents that he has reviewed the nursing notes and agrees with the documentation - then you can use that information to select a code.  If the physician orders tests you need that medical necessity information to justify the tests ordered.

I hope that helps a little.


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## mitchellde (Apr 18, 2011)

Can you provide an example of what you are talking about? and are you coding hospital or physician.
Whlle a physician can referr to the nurses note and agree, the nurse cannot render the dx.  The nurse can document the chief complain, the vitals and the ROS, but they cannot render the dx and have the physician agree or disagree.


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## AmandaW (Apr 18, 2011)

I think I read in one of the recent Coding Edges that the doctor's signature has to be on everything or it's not a legal document.  That's what we do in my practice.  The nurse can enter a dx but to be billed out it has to have the doc's signature on it or it's not legal and binding.  Right?


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## mitchellde (Apr 18, 2011)

A nurse cannot rnder a dx, they can report observations and signs and symptoms on a triage note, but they cannot render or "enter" a diagnosis, this is the physicians area of expertise.  Check with your area nursing school for this information they will be able to share with you what a nurse can and cannot by licensure do.


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## MJ4ever (Apr 18, 2011)

I agree with mitchell

http://www.netplaces.com/new-nurse/your-scope-of-practice/nurses-never-diagnose-disease.htm


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## AmandaW (Apr 22, 2011)

Maybe I'm confused.  An example of what I'm talking about is one of our doc's nurses will enter a return order for labs, chemo, phlebotomy, etc. They'll say CBC and CMP weekly for breast cancer or anemia, or whatever dx. and the doctor signs off on it. 
And with our EMR they enter dx's into the system and it can be kind of transfered over to the office note so now it's apart of the office visit note-once the doctor signs off on his or her note, it's done.  It's a legal document that has his signature on it.  Everything within the note is billable.


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## AmandaW (Apr 22, 2011)

...I agree with Michelle.


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## AmandaW (Apr 22, 2011)

...I did want to say though of course the dx's that are entered in the nurse notes, return orders, etc. will originally come from the doctor...but even if they are a new patient and hasn't had an office visit or anything yet, if it happens to be a nurse that enters a note in the system ordering a phlebotomy for polycythemia it is ok to bill out as long as it has the doc's signature on that order.


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## pinters4@aol.com (Feb 17, 2016)

*coding from nursing notes, is it ok or when is it ok?*

When a patient has come in the hospital for surgery whether it is elective or not and that surgery is cancelled by the physician or by the patient is it ok to just code that the surgery was cancelled without a physicians order?  Is it alright to code from the nursing notes or should you have the physician write a note in the progress notes or orders and sign and date it?  We have been having a debate about this at the facility I work at.  They feel that if it was the patient's decision to cancel we don't need anything from the physician that if that is stated in the nursing notes that is good enough to code from.  Is it ok to code stages of ulcers from the nursing notes if the physician does not state it in his or her documentation?  Thanks for your help.


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