Wiki Diagnosis entry

[jcgiordano]

Is there a written rule/law for the state of Michigan that states 'who' is allowed to enter diagnoses into a patient record? We have a provider that is wanting his medical support staff (MSS) to enter diagnoses for new patients or new diagnoses for established patients in their charts. He is leaving it up to the MSS to choose the diagnosis. I don't feel that is ethical?

 

[thomas7331]

Not sure I exactly understand the situation you're describing. Is the provider having the staff choose and enter the diagnosis codes, or is he actually having the staff choose the diagnosis itself for the patient? The former is not prohibited by any laws that I know of. It's not a great idea to have untrained or uncertified staff selecting codes just due to the potential for error, but there aren't any regulations about who can code. But if the staff are being asked to actually diagnose the patient, that is something that's prohibited by law - it would fall under the category of practicing medicine without a license, or practicing outside the scope of their license.