Wiki Injection Template Documentation Guidelines

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KStaten

KStaten

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It has been to my understanding that the provider is responsible for documenting the procedure, exam, and plan (unless he/she is assisted by a scribe).

IF a provider decides to start using a template (such as for routine joint injections), which has drop-down menus to enter the correct injection site/ drug/ concentration/ dosage etc, must he or she be the sole person selecting all of this information within the template, or may this be done or partially done by the MAs or other staff?

Thank you in advance!
 
csperoni said:
If the staff are acting as scribes, it should not matter whether they are typing free text or clicking radio buttons. It must be recorded that it was done by the scribe, and reviewed and signed by the physician.
I believe some MACs (but not CMS specifically) also require scribes to sign the record.
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Thank you. This has been my understanding, as well. If the MA is acting as a scribe, he/she must document that is his/her role. However, if an MA is performing the regular duties of an MA (and not indicating that they are acting as a scribe) he/she cannot enter this information. I may be incorrect in this, but I seem to recall that an MA cannot switch roles--from acting as an MA to temporarily acting as a scribe during the same encounter. (?) I can certainly understand where this would be more convenient for hands-on providers who may be short-staffed, so perhaps this has changed as long as the sections which have been scribed are properly documented as such. (?)
 
It's a grey area and can get very tricky. The role of a scribe is different than a role of an MA. Permissions in the EHR would differ as well. All the advice is it shouldn't be the same person, not that it can't be the same person. The AHIMA article states if it is 1 person, they should be logging onto the system differently (with the according permissions for the role performed). If you are deciding that it will be the same person, they need to be well trained about what they may or may not do in each role. For example, an RN can call in a prescription, but not a scribe. A scribe can enter a prescription (clinician must sign), but an RN may not. So if the same person is an RN and scribe, the lines for roles, responsibilities and permissions will blur.
 
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