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Ethical Question...

Posted

Question—-

is it illegal for someone who is not a scribe rounding with a physician to enter MD notes?? Someone in an office off the unit who never sees the patient or has a medical background/ and does not converse with MD other than on a weekly basis or so..... I know the answer but I feel like I need to hear from others how absurd and illegal this is. Or educate me if I am wrong. Very very troubled! 

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

It's hard to say without more context, it's not unusual for clinic staff to enter notes on behalf of the MD, so long as that is made clear.  Are they writing notes meant to appear as though the MD was writing them?  Are they falsified notes used to justify billing?  

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 44 years experience.

Regulations vary from state to state AND facility policy and procedure.

What is your facilities P+P --then members can chime in.

FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Community, Nurse Manager. Has 5 years experience.

Is this person rounding with the physician or not?

It doesn't really sound like an ethical question. 

 

What actually is the person's role, what kind of notes are they entering and what is your role that allows you to have all the details about this?