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Documentation requirements for primary surgeon

Amy Posted Mon 17th of March, 2014 13:47:54 PM

Is there a documentation guideline that states only the primary surgeon can dictate the op note? We have a case where the assistant surgeon dictated the entire op note. He starts by saying "This is Dr _____ dictating for Dr. ______ . Under the procedure heading, he lists himself as the assistant, and the other Dr. as the primary.

SuperCoder Answered Wed 19th of March, 2014 04:33:27 AM

This document covers all sorts of indication regarding physician signature in the medical record. If the surgeon is BILLING for the surgery as primary surgeon, it is required that they at least SIGN the operative report. If they have someone else dictate it, they must at least test that the information in the report is accurate. Many hospitals have a requirement that the primary surgeon dictates and signs their own operative reports, so check with the hospital contracting department. The other entity that would be involved is the physician's malpractice insurance company. They often times have guidance for providers on these issues. If the surgeon does not sign their operative report they are opening up themselves to potential malpractice if something goes wrong!

Amy Posted Wed 19th of March, 2014 08:08:26 AM

Thansk for the reply. The web page link does not allow me access. I copied the link but it still doesn't work.

SuperCoder Answered Thu 20th of March, 2014 11:14:24 AM

I am sorry for the link. The same info was pasted from that link. If any doubts, please revert.

Thanks,

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