BS&SC
Networker
I have a couple of physicians who rely on what I think is the auto-generated reports done by nurses/hospital people...?? I am in Cerner, btw. The physician's name is mentioned as the doctor doing delivery and there are notes on laceration and a continual thread of time-stamped things that occur during delivery. But I am not seeing what the majority of the other providers do, which is a personal note speaking to the fact they, as provider, saw the patient...how she progressed to pushing stage...how the delivery went...etc. Isn't this summary note from the provider proper documentation? Is there a good resource for proper documentation for physicians in OBGYN?