Re: Physician compared to nursing documentation
I'm a NP in an ER that uses IBEX/PICIS (not a T-sheet; but we USED to!)
The RN's and NP/MD's share the SAME: Medical, Social, Family, Surgical history sections.
I do not know what the policy requires of the RN's to chart in these areas, but often times they do gather this history and we (providers) can see what they've entered.
We can choose to check a box for each that says "reviewed RN documentation" or "agree with RN notes" and this gives us credit for the appropriate level exam for billing purposes, HOWEVER,
the "wise" provider reviews all this and asks these questions themselves also.
There are SEVERAL instances where the info the RN entered is incorrect or inappropriate and has to be corrected.
I NEVER check the box that says "agree with RN notes"...I use the "reviewed RN documentation" instead as this doesn't imply "agreeing" with it.
-MB
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