Wiki Interesting use of EMR - any thoughts?

[sparkles1077]

Hello fellow coding professionals,

So, got a client that uses the transcription/EMR combination. The HPI exam and MDM are dictated and then pulled into the note by the midlevel. The LPN completes the ROS and PFSH. The CODER (yikes) pulls the ICD codes into the assessment and plan. Each section generates a signature when someone touches the charts. The transcriptionist does type in the name of the MD at the bottom of the HPI and the MDM. However, with the coder's signature on top, it really looks like the coder wrote the note. Does anyone know of any references that speaks to the dangers of having nonclinicans access the EMR documentation? I typically see this limited to clinicians.

Also, for dictations, unless they are using dragon voice, I typically see the date of dictation and date of transcription along with initials by transcriptionist. Does anybody know where the dictations rules are? I have hunted and can not locate anything.

Thank you

 

[mitchellde]

Coders are allowed to access clinical notes. It is totally appropriate for the coder to be the one assigning the codes. I am uncertain regarding the signature placement, however as long as it is just identifying that she is only coding the record, I have no issue with it.

 

[DRCompliance]

I disagree. I coder can access the note and assign a DX code and correct me if I misinterpreted but are you saying that the coder is actually entering the DX in the assessment of the Providers note?
It is good that the system does log who is doing what but this sounds risky to me, that note is communicated to other providers etc, if coder assigns incorrect code that a misdiagnosis in the note ???
D'Arcy Scalzo, CPC CEMC

 

[mitchellde]

How can a code assign a mis diagnosis? A code assigns the code based on what the provider has documented as the diagnosis. This means the coder must access the clinical not and read it to assign the codes, not the diagnosis as that is assigned by the provider. But the diagnosis code is assigned by the coder after reading the note.