Wiki Progress Note Signatures

[Agilbert3]

I am wondering if there is any hard rule about a physician signing off on a progress note before it's complete.

I have an issue of receiving encounter forms and notes( it's a paper-based clinic) that may have the encounter form fully filled out and signed, but missing dx, exam, and ros in the note. The notes are usually signed, though.

I may be searching it the wrong way, but I thought the signatures were meant to indicate the physician has authenticate what was done during the visit.

 

[csperoni]

Signing is the LAST step

Yes, you are correct that there should not be a note that is signed, but not finished. A note can always be amended, or corrected after signing for an omission or error, but I have never in my 25+ years of working in physician offices heard of a physician signing a note without completing it first. You indicate the "encounter form" is fully filled out. Is that just an internal billing sheet and not the medical record? It would be a HUGE red flag to me that clinicians are signing medical records and then LATER documenting the content. Offices frequently have issues that the record is not signed/dated (or not signed legibly back in paper days) in a timely manner, but this is definitely a new one for me.

 

[Agilbert3]

We are a RHC and the encounter forms used to be used for billing. But since ICD-10, it was implemented to copy the notes and attach to the encounter form for the coders to abstract.

Unfortunately the providers tend to want to put everything on the fee ticket, but not in the note. But also vice versa sometimes. If there is inconsistent information, the providers get back the chart, the note, and a query asking them to confirm or clarify the dx.

It is hugely poor practice, but I couldn't think of a reference to show and educate them about this.