Wiki amending another physician documentation

[paula f3]

Is it legal and acceptable for a physician to amend another physician's documentation? For instance, I code for a clinic with numerous providers. One provider will see the patient and a couple of days later the patient returns, sees another provider. There have been instances where the provider that sees the patient the second time , more than 24-48 hours and will amend the previous provider's documentation.

Our clinical director is saying that it is legal. I know that a physician can amend his own documentation, but not sure about the later.

Please advise.

Paula

 

[mitchellde]

I do not see how this could be legal but you should check with an attorney to be certain. However how can a provider that was not present during the encounter amend the documentation of that encounter. Even if when he is seeing the patient the next day the patient says something that is not previously documented, there is no way to know if that information was indeed passed on to the provider in the first encounter.

 

[Evelyn Kim]

I would agree that it is not legal. If the provider seeing the patient the next day they can make a note in their docoumentation of any correction the patient mentions, but cannot "change" another provider's note.

 

[ckhuntcpc]

What about a situation where the provider is no longer employed at the facility? I have one where the provider documented 2 physical exams, however, upon review of the entire account, one of the exams appear to be a copy and pasted exam from a different provider's note. My provider performed her own exam. But, since she is no longer here, we are unable to get her to make corrections or additional notes. The lead provider for the clinic is willing to document that the provider is not longer here and the 2nd exam was documented in error.

Any assistance would be greatly appreciated!!!
Thanks

 

[jaud63]

Amending a Physicians Note

I agree with the comments that the services should only be documented by the provider who saw the patient. If the documentation was changed later by a different provider it could render the documentation invalid which could become a compliance related issue later. Additionally, the billing has to include the 1st doctor if the documentation was complete. I'm stating this by making the assumption that the changed note from later is not a simple review/result of tests performed that had to take place at a later date.