Wiki Electronic Medical Records

[angelkat]

I have a question regarding the entering of charges once a patient has been seen in office. The front desk staff are responsible for entering charges for patients after their office visit. My concern is that they are signing in under the physician's User ID and Password, entering the procedure and diagnosis codes that the Dr has assigned to the visit, but because they are responsible for charge entry, they are signing the note for the Dr. I am concerned as I was always told, we are not to go into a patient's electronic medical record to add or change anything? Could someone please give me some feedback? Am I correct on this issue?

 

[scadykat]

Hey Angelkat,
I understand and support your concern. HIPAA & the HITECH Act have access control specifications listed as: each user must have their own unique user ID for tracking and audits. Hope this information helps.