Scottkuntz1
Contributor
I am wondering if anyone in the medical office can write a portion of the note, or does it all have to be written by the doctor???
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Wiki SOAP Notes?
- Thread starter Scottkuntz1
- Start date
dclark7
True Blue
The note has to be written by the provider (either doctor, PA, APRN). Ancillary staff can record the vital signs (as part of the exam), the ROS and PFSH, however, the physician must document that he reviewed the information that was taken by other staff.
Wendyh50
Guest
Check CMS for the official guideline
Hello,
Transcription is acceptable. The physician is supposed to read or write the Objective, assessment and treatment. Subjective and HPI information may be taken by a qualified individual but must be reviewed at the time the patient is seen.
Remember it is the physicians license on the line, they should care enough to write or say their medical expertise.
Hello,
Transcription is acceptable. The physician is supposed to read or write the Objective, assessment and treatment. Subjective and HPI information may be taken by a qualified individual but must be reviewed at the time the patient is seen.
Remember it is the physicians license on the line, they should care enough to write or say their medical expertise.
Scottkuntz1
Contributor
Thank you both for your replies they have been very helpful!!