Debunking Myths About Who Can Enter Information Into the Patients’ Medical Record

April 10, 2023
Entering Information Into the Patient's Record

As you are likely aware, on Jan. 1, 2021, Medicare requirements changed with regard to the billing of Evaluation and Management (E/M) services such that the level of service is no longer determined by the history of present illness, social history, family history, review of systems or physical exam. These items may still warrant documentation for clinical purposes. However, the myth persists that the physician must re-document staff entries into the record. The truth is that there are no restrictions as to who can input this information into the patient’s record. These elements could be entered by the patient, a clerical assistant, a medical assistant or other clinician. Medicare requirements now allow physicians to “verify” the staff documentation of components of E/M services, rather than redocument the work, if this is consistent with state and institutional policies.

In its effort to debunk regulatory myths, the American Medical Association (AMA) has produced this useful fact sheet, “Who can document components of E/M services?”


Caroline Fife, MD

Dr. Fife is Co-Founder and Chief Medical Officer of Intellicure, Executive Director of the US Wound Registry, and Editor of Today’s Wound Clinic.

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