Wiki Wound Clinic Documentation

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sjmccarl52

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We have a Visit Note form that we use in our wound clinic. The information is filled in by the nurse. The physician reviews, adds type of debridement and instruments used and then signs off on the form. He also dictates a note but the note does not include the information on the visit note form. Can we include a line stating "Please see visit note for procedure details" and be covered should we be audited? The problem we are encountering is that the note is in the computer system and the visit note is paper. The visit note cannot be scanned in our present hospital computer system. Any thoughts out there?
 
Cross referencing

As long as you can point an auditor to the correct place to find the documentation, you should be fine. Ideally the handwritten document will ALSO have a reference such as "Dictation # 12345" to let someone who is looking at the paper trail know they should also check the computer.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Just checking

I too work in wound clinic. Our assess is done by the nurse and the do checks off that he agree with assess and signs off. Is that adequate?
 
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