Thinus van Rensburg wrote:
It was interesting and relevant to this subject to see that my insurer
(MDASA), still requires doctors to sign and date their progress notes - was
going through their on-line practice assessment recently. I run a paperless
system - wonder if they'll be happy with the fact that an entry was made
under my login and dated by the system.
MDASA's advice to sign and date your progress notes has nothing to with
Medicare Australia and Medicare benefits.
The Medicare legislation does now require that appropriate notes be made
of consultations for which Medicare benefits are being claimed by the
patient. This is so that, in cases of suspected fraud, they can have
some idea of whether the content of the consultation met the
requirements for a Medicare benefit having been paid at whatever level
of item number was being claimed. In other words, did the content of
the consultation justify the claim for a level C or D consultation? See
the fascinating little book that Medicare Australia recently sent us all
detailing their successful cases against GPs who had claimed for level C
and D services but whose case notes were nil or very brief indeed,
making it very difficult for anybody to believe that the consultations
satisfied the requirements for level C or D.
MDASA advises the dating and signing of progress notes only so that in
the event of a claim being made by a patient, it is easier to say when
and by whom the progress note was written, because this can help the
accused doctor's defence. MDASA is still focussed on the quaint past
when all doctors wrote progress notes by hand. I believe that MDASA
would be very happy with our electronic records that clearly show the
date and name of the person who wrote the record. They don't really
want the note 'signed' - they really want just to know who made the
entry. It's a careless use of language by MDASA.
--
Oliver Frank, general practitioner
255 North East Road, Hampstead Gardens, South Australia 5086
Phone 08 8261 1355 Fax 08 8266 5149 Mobile 0407 181 683
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