Outpatient Facility Coding Alert - 2008 Issue 3
DOCUMENTATION: Chart Auditors May See -- But Not Agree With -- "Seen and Agreed" Stamp
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Article Overview
This article covers documentation requirements for physician notes in settings where residents, nonphysician practitioners, or scribes assist with care. It explains why the topic matters for compliance and audit readiness, and summarizes the general CMS guidance and professional commentary discussed in the article.
Why This Topic Matters
Accurate attestation and signature practices affect documentation compliance, audit defensibility, and whether medical records support billing for professional services.
What You Will Learn
- How physician documentation attestation is discussed in the context of teaching physician services.
- What concerns are raised about stamp-based note approval practices.
- How scribe involvement is described at a high level in relation to documentation authenticity.
- What CMS guidance is referenced regarding acceptable documentation practices.
Who Should Read This
- Physicians
- Medical coders
- Coding auditors
- Compliance staff
- Medical practice managers
- Hospital documentation staff
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