Anesthesia Coding Alert

Question: Some of our CRNAs have a habit of documenting their work on the patient’s record (could be vitals on hand-off note) and not signing off, but the attending signs off. I am told by my superiors that this is acceptable. I was taught that anyone who documents services in the record needs to sign the record. If the CRNA is scribing, doesn’t the attending need to state this? What guidelines are available that I can show them?

Oklahoma Subscriber

Answer: Show your providers this information from the CMS State Operations Manual: “All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided.”

In other words: If the CRNA is providing a service to the patient and documents that service within a hospital medical record, CMS regulations require the CRNA to authenticate that entry.