Wiki What can the MA record in the EMR

[AKAJBART]

I've read so many different things, what is your opinion on this?

Can the MA record: CC, ROS, PFMSH & vitals?

And then Dr. needs to record everything else?

I've read many things that state that the Dr. has to record the CC, and the MA cannot. Who does what in your office?

 

[erjones147]

Can the MA record: CC, ROS, PFMSH & vitals? yes

And then Dr. needs to record everything else? yes

I've read many things that state that the Dr. has to record the CC, and the MA cannot. Not true; I'd love a reference that you have read stating that the MA/LPN/RN cannot record a CC

 

[RebeccaCross*]

Check with your MAC...

Jurisdiction 11 Part B
E/M Weekly Tip: Ancillary Staff
Ancillary staff may only document:

Review of systems (ROS)
Past, family and social history (PFSH)
Vital signs
These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Jurisdiction-11-Part-B~94MHC73301