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Practice Management Alert

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Test Your Knowledge of Original Documentation Requirements

Published on Mon Jun 14, 2004

Determining what constitutes original documentation can be tricky when carbon copies and signature stamps are involved. Test your knowledge by deciding how you would answer the two real-life questions below.

Question #1: We now have our allergy testing forms on duplicate carbon forms. Our doctor has been giving out the "original" to the patient and keeping the carbon copy in our chart. I always thought the originals should be kept in the office, but the doctor says it makes no difference, and he considers the carbon copy as an original. Is there an official rule regarding original documentation requirements in the patient's chart? Question #2: Our doctor is stubborn and insists that he wants someone to stamp all of his transcribed dictations with his signature stamp. Doesn't proper documentation procedure mandate that doctors manually sign all their progress notes for daily patient office visits and hospital rounds?
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