Wiki E/M documentation "author"

[Jenna000]

Good Morning,
i am 99% sure i know the answer to this, but i am looking for back up. I have a Dr charging for an admit, and it is a typed document in the EMR, not a dictated note. Behind the HPI, Exam, ROS is the RN's name not the DR's name. The dr did sign the note, but other than that it looks like the RN did the rest of the admit. At a previous coding job, we were told to tell the DRs that couldn't happen because that is out of the RNs scope of practice and to someone outside of our hospital it could look like the RN is doing the admit. I still feel that way now, however, I am now working with a DR owned clinic now and they have been doing things there own way for along time. So i want to make sure i can back myself up before I open this can of worms.

Thanks in advance for any help!
Jenna

 

[jimbo1231]

Tricky Situation

Jenna,

You are right to be concerned about what could appear to be a fraudulent practice. But a couple of clarifications. Do you know whether the physician is actually providing the service but not authenticating on your charts, or are you concerned the the physician is taking credit for services rendered by the nurse? Either one is problematic, but the second is definitely a greater concern. If it's a question of the physician doing a better job documenting but they are actually are providing the service, that needs to be corrected. EMRS typically provide for physician authentication of everything they did. If the physician is dictating in the first person and signing the chart, and you are not concerned that they are taking credit for nursing services, that is a documentation correction.
But if you are concerned that the physicians are taking credit of Nurse examination etc, that is a big issue. I did consulting for a large Oncology pratice in the 90s that was in a world of hurt with the Feds for just that practice. I'll be happy to back you up if you need it.
The only other possibillity is if the physicians are using the Nurse's as Scribes. But that doesn't sound like the case here, and woulddn't be a good idea anyway.

Jim

 

[Jenna000]

I don't think they are taking credit for work they are not doing, i think it is just a documenting issue. Some of the don't like the computerized system, so the RN puts it in for him and he signs it, the problem is the RNs name is behind everything not his. I just wanted to make sure before i try and explain that this is an issue, being the "new" girl and stirring the pot has been what i have done here becuase no one has been checking it for so long.

 

[jimbo1231]

A Pot that Needs Stirring

I do think it should be mentioned to somebody there that you are comfortable with. If they need the Nurse's to be scribes because they are too busy or hate the EMR, they should probably look at a Scribe Service.
Good Luck