Who Has to Complete Documentation by When?

June 1, 2007

If the physician sees a patient and handwrites a note, may a physician’s assistant (PA) later dictate that consultation? What if the PA did not physically see the patient? Does dictation need to be done that same day?

Question: If the physician sees a patient and handwrites a note, may a physician’s assistant (PA) later dictate that consultation? What if the PA did not physically see the patient? Does dictation need to be done that same day?

Answer: I don’t know of any Medicare policies about this, but I have two concerns anyway:

First, what a waste of time. You’ve now got two people documenting the visit. Can your physicians jot a few notes during the visit and then step outside the exam room and dictate before moving on to the next patient? The April 2007 issue of Physicians Practice includes an article on using scribes to document visits. (Read “Could You Use a Scribe? ” for more information.) This may be a better option if physicians in your group just can’t do their own documentation.

Second, there are bound to be errors. The PA, even if she saw the patient, probably wasn’t in on the entire visit and so can’t know everything that was addressed. Some things will be assumed, creating a compliance risk, and others will go unmentioned, creating a revenue leak.

As far as time goes, the longer the documentation waits - no matter how it gets done - the more likely the provider is to forget something, and so the longer you wait to bill. The ideal is to have everything documented within 24 hours, and the “super-ideal” is to do it at the time of service so the patient can be billed at check out.