Wiki E/M in the EHR

[KATHY WILHELMSEN]

In the electronic world the provider signs off, ?authenticates?, at the end of each office visit note. If the office staff are populating/documenting the review of systems and PFSH, does the provider need to document that he reviewed those areas in addition to signing off, ?authenticating? the note?

 

[blaymon]

With the EMR's I have worked with, at the end of each history section (meds, allergies, PFSH, ROS, problem list) we have to click a button stating we reviewed it. As far as I know, this meets the requirements for reviewing those sections.

 

[emcee101]

There are so many different EMRs and all of the function differently. I like the feature that blaymon has available to use, but in the EMRs that I have used this is not available. My line of thinking (right or wrong) has always been that as a trained and licenced medical professional it is well within the physician/QHP's responsibility that when they sign off on the note they are attesting to the accuracy of EVERYTHING in it.

At the end of the day it is the provider's name and credentials at the bottom signing off and they are the ones that are ultimately responsible for the content of the medical record. I work for a large health plan doing medical record auditing and analysis. We follow CMS guidelines for medical record signatures and there is nothing that I have seen that discusses the office staff having to sign for the parts of the note that they document.