Wiki signature for each section of EMR

[arizona1]

Good Afternoon,
I am reviewing a medical chart that listed chronic conditions in the Problem List.

The provider documented one sentence, as follows; “The Problem List was reviewed and addressed during today's visit; all diagnoses are stable unless otherwise documented in this visit's note”.

1) Would this meet CMS guidelines - face to face in office and addressed/documentation - stable.
2) the EMR provides for a signature to be at each section of the note. He did not sign for the Problem List specifically but did complete a correct electronic signature and closed the record.

Thank you.

 

[acanny1]

Good Afternoon,
I am reviewing a medical chart that listed chronic conditions in the Problem List.

The provider documented one sentence, as follows; “The Problem List was reviewed and addressed during today’s visit; all diagnoses are stable unless otherwise documented in this visit’s note”.

1) Would this meet CMS guidelines - face to face in office and addressed/documentation - stable.
2) the EMR provides for a signature to be at each section of the note. He did not sign for the Problem List specifically but did complete a correct electronic signature and closed the record.

Thank you.

The conditions on the problem list must have a MEAT: monitoring, evaluation , assessment and treatment. The physicians most document the status of all conditions , the medical record must a signature that states that is electronically signed, or authenticated by;

 

[arizona1]

thank you for your reply.

This particular template allows for a signage at each section of the note, i.e.Vitals (Mary Jones, MA 051015 8:30am) ROS (John Smith, M.D. 050115 8:45am), Exam (John Smith, M.D. 050115 8:55am) Assessment (John Smith, M.D. 050115 9:01am)

If the signature at the bottom of the progress note was not authenticated, would it still be ok to accept the documented diagnosis listed in the assessment, and this section of the note was signed off by the provider.

Thankyou

 

[sparkles1077]

The conditions on the problem list must have a MEAT: monitoring, evaluation , assessment and treatment. The physicians most document the status of all conditions , the medical record must a signature that states that is electronically signed, or authenticated by;

Do you have a reference for MEAT? I have not heard of this before

 

[mitchellde]

Good Afternoon,
I am reviewing a medical chart that listed chronic conditions in the Problem List.

The provider documented one sentence, as follows; “The Problem List was reviewed and addressed during today's visit; all diagnoses are stable unless otherwise documented in this visit's note”.

1) Would this meet CMS guidelines - face to face in office and addressed/documentation - stable.
2) the EMR provides for a signature to be at each section of the note. He did not sign for the Problem List specifically but did complete a correct electronic signature and closed the record.

Thank you.

Are you stating this was all that was documented?