Corporate Compliance

Nursing documentation

Compliance Monitor, June 9, 2006

Q:I understand nursing documentation can not be used to support codes, however if you are looking at ER documentation and the physician stated he/she had review nurse's notes and agreed with documentation, does that make the nurse's notes supporting documentation?

I feel it does as the physician has referred to the documentation.

My medical records department, however, feels that unless the physician specifically mentions each sign and symptom in nursing notes, it is not codeable. Who is correct?

A: Your Medical Records Department is correct, nursing department documentation cannot support codes. If the physician agrees with the nurse's documentation and that documentation is necessary for coding, he or she must write it.

We can not assume what the physician means when he or she indicates that he or she "agrees with the documentation." Agreeing with the documentation may mean in general terms and not "in fact." We alleviate "assumption coding" by placing the responsibility on the physician to write his impressions/diagnoses.

Thanks to Victoria Druding, RN, PhD, LHCRM a compliance officer with Zavata, Inc. in Conshohocken, PA for answering today's question.

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