Medical Records Documentation
Documentation of medical records must be dated and signed or countersigned by the billing physician. Another physician’s signature is not acceptable, even if he is in the same department or service. In addition, Federal regulations require that the patient know the identity of the attending physicians through direct physician/patient contact. This includes physicians to whom responsibility for treatment is transferred during periods of hospitalization.
Current and accurate documentation is required in the patient’s medical record for the following:
- Clinic visits
- Consultations
- Inpatient care
- Outpatient consultations
- special tests and/or procedures
- Whenever a physician from the Department of Anesthesiology participates in the respiratory care of a patient, a progress note containing pertinent facts regarding the specifications of the prescription and the effects of therapy (including any adverse reactions) should be written in the patient’s medical record.
