2 part question on must nurses sign note that is part of the visit with MD

1. When a Nurse sees a pt should they sign their note.
2. Also, when nurse brings a pt back into the room and does visual acuity etc prior to MD seeing pt is it required they sign their note in addition to the MD or is the note the MD's?

Nurse

yes and Yes

nurses signing notes

thanks Nancy, the DR is pushing back stating the note is theirs and the nurse need not sign it......

Initials are fine...

if that will make the doctor happy. But the malpractice insurer will reinforce that every entry in a medical record should be authenticated by the person performing the service.

nurse

That is interesting. In Ophthalmology, for example, the specified eye exams have criteria for the exam that a physician/Optometrist must document when performed to bill an Intermediate or Comprehensive eye code. Since when is a nurse allowed to conduct the physical exam and the doctor take credit for it? A physical exam is not within the skills of an RN for code assignment.
A LLP (PA or NP) may bill as allowed by State "scope of practice" laws, under Incident-to for a Medicare patient but the physician must see the patient for the Initial visit and condition. Subsequent visits for that condition may be performed by LLP, under Incident-to (Medicare), and be billed under MD number. A new patient cannot be billed as Incident-to by a LLP.
The nurses note and participation is usually noted and signed/initialed (RN), followed by the physician evaluation and participation, signed by M.D. Ancillary staff (RN), can only do the ROS and PFSH. The physicioan must then comment on negatives and positives of presenting problem(s).

nurse notes signed "usually"

That is the push back from the DR...the nurse rooms the pt and the DR sees the pt. Where is it cited that it is required for an RN, LPN, or MA sign or initial their portion...vitals, visual acuity, ROS, PFSH ? IS it OK for them NOT to sign or intial? And how is this handled in the world of EHR? In paper we had nurses sign or intial their dictated note but when part of the record or visit if their notes were on teh superbill it was signed or itnitaled but not part fo the record...it went in as the MD, the MD dictated the note, signed the note and then the note was placed in the record. The superbill went into a box into storage. I can't locate anything specifically on the state statutes or the malpractice carrier in regards to nurses signing or intialing anything they document. It refers to Practitioners only. WE are all EHR now...Where do I go next?

Oh more EMR blues...

I have my MA put her initials after the Chief Complaint that she collects and documents in our EMR. You are right, I cannot prove she did the medication reconciliation or even the vitals. (If the nurse is doing the ROS, PFSH , etc the doctor better indicate that she reviewed the entries- an auditor could get you on that if they figure out how to see who entered what info in the EMR.)You win. But I'll stick by my answers on a paper chart- initial entries.

signatures

Any one who enters any information into the medical record should sign the note. Initials are okay, if there is a signature log.

If you question this, call your malpractice carrier and ask, "should we know who enters information into the medical record, or can it be anonymous?"