Wiki Updating provider documentation

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jennx1032

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One of the providers in my office who often leaves things out of the procedure note such as moderate sedation time is asking me to update the note with this information with the providers permission and instruction. I am pretty sure only providers are allowed to update their procedure notes, can anyone point me in the right direction has to where I can find documentation on this to present to my provider. TIA
 
While I am unable to find references which explicitly state that the provider has to be the one who amends his own note, I believe it is strongly implied. At any rate, the original author/provider of the note should at minimum verify the changes. I did get this from Palmetto GBA:
"The record must provide a reliable means of clearly identifying the original content, the modified content, and the date and author of each modified record".

If I was auditing this record, I would question why a non-provider (assuming you are) would amend patient notes, and start raising flags and flash red lights. I would personally think it would be in the provider's best interest to modify/amend any notes that should be noted, and I doubt an attestation would suffice.

Other sources:
CMS Integrity Manual 3.3.2.5 - Amendments, Corrections and Delayed Entries in Medical
Documentation
Noridian (my MAC)
Palmetto GBA


Hope this is helpful!
 
You can write it, as long as he signs it and includes a statements that he agrees to its accuracy.

Per CMS:

The medical record must clearly reflect:

  • Who performed the service
  • Who recorded the service
  • A notation from the physician/NPP that he/she reviewed the documentation for accuracy
  • Signed and dated by the performing physician/NPP

There is no reason that this would not apply to amendments any less than to the main body of the note.
 
I don't see where this would be much different than having a scribe documenting. I agree that the provider does need to clearly document his/her agreement/review with the documentation that you add though.
 
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