Wiki Physician Assistant Documentation

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marklerner

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Does anyone know if a Physician Assistant acting as an assistant in surgery must write his own operative notes or can the surgeon do it and dictate what the PA did in detail. It is anywhere in writing? Also is it documented as to how detailed it should be.

Mark Lerner CPMA
 
marklerner said:
Does anyone know if a Physician Assistant acting as an assistant in surgery must write his own operative notes or can the surgeon do it and dictate what the PA did in detail. It is anywhere in writing? Also is it documented as to how detailed it should be.

Mark Lerner CPMA
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The surgeon should document any assistants used, and a basis for medical necessity, within his/her op report; the PA does not need to dictate a separate report. Here's a great article from AAPC; you can also google "assistant surgeon documentation requirements" for a lot of resources.

https://www.aapc.com/blog/25432-prompt-proper-assistant-at-surgery-payment/

HTH!
 
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