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Medical Review Frequently Asked Questions

Q1. Do hospital protocols ever come into play when an order for a drug or test is changed by a non-qualified ordering entity or are they required to be co-signed?
A1. No. Even if the state licensure of the Pharmacist or the Hospital policy allows for this, neither the pharmacist or the nurse is an approved Medicare provider and cannot sign orders for Medicare patients. Such orders will require the physician or non-physician practitioner to co-sign the order.

Q2. Are late entries acceptable in a patient's chart? Is it acceptable to add a late entry after the patient is discharged?
A2. This is addressed in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5. These entries must be clearly signed or initialed, dated, and identified as a late entry. If the person making the entry can legitimately confirm that the entry happened and has direct memory of that occurrence, a clearly labeled late entry is reasonable. An entry should not be made if this cannot be supported. The longer between the time of the event and the time it is documented, the less detail is generally correctly remembered.

 

Last Updated Sep 20, 2017