HCPro, JustCoding Inpatient - 2015 Issue 41 (November)

Q&A: Coding from unsigned operative notes

November 4th, 2015

Q: Is there guidance on reviewing a record, such as an operative note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including that information in the review worksheet. Do you have any recommendations for this?

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