Primary Care Coding Alert

Question: At a seminar I attended, the speaker stated that a physician should never put dictated but not read on his dictation. Also, our hospital medical records contain the phrase I authorize my name to be mechanically affixed to this report, signifying that I have dictated this report. Are these recommended practices?

Karen Hood
Cleveland, Tenn.

Answer: The statement dictated but not read does not authenticate the record. During an audit, the Office of the Inspector General (OIG) most likely would find that the records were not authenticated and, therefore, the service was not rendered. Remember the rule of thumb: If it wasnt documented, it was not done. Dictated but not read indicates that the content is only a preliminary report that may contain errors, which has not been confirmed by the provider as a final and valid reporting of the care provided. In addition, the American Medical Association (AMA) guidelines for authentication of a medical record clearly state that the record must contain the physicians first name, last name, certification, and a date.

Note: Professional coders also point out that use of this phrase indicates that the doctor is too busy to look at the record, which may be interpreted as poor patient care. In addition, it leaves the doctor vulnerable to medical and legal problems if the chart was in error and someone based future care decisions on the erroneous information.

The use of the phrase I authorize... is widely used and allows the hospital to reduce the number of charts outstanding, pending physician signature. This statement, however, does not protect the physician from transcription errors. It is highly recommended, for the protection of the provider from questions of fraud and for compliance, that he or she actually authenticate each report.