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Wiki Biopsy Documentation
- Thread starter cyndeew
- Start date
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- Tags
- biopsy documentation
mitchellde
True Blue
I would query the provider for sure. Did he fail to documet that a biopsy was performed? Or was it intentional?? Is the path report for the correct patient. There are many questions to be answered. But you are correct in that if he performed a biopsy he must document that he did.
Hey Cyndee,
As mentioned by another person in the posts, physician should be appropriately queried as to the accuracy of the documentation regarding the biopsy.
Should his response to the query indeed include the biopsy service, then the record can be updated (by the physician). This would be considered a "late entry" or "addendum" to the record. There doesn't seem to be any particular time frame set in stone for this type of entry in the record. In general, my research has found the same statement repeatedly.... "addendums should be documented as soon as possible and, while there is no official time limit, the entry becomes less credible and reliable with the passage of time" (a legal aspect).
Physician would also need to identify the new entry as an “ addendum” or "late entry" and reference the original entry AND, use the current date and time on the addendum entry.
Hope that helps!
As mentioned by another person in the posts, physician should be appropriately queried as to the accuracy of the documentation regarding the biopsy.
Should his response to the query indeed include the biopsy service, then the record can be updated (by the physician). This would be considered a "late entry" or "addendum" to the record. There doesn't seem to be any particular time frame set in stone for this type of entry in the record. In general, my research has found the same statement repeatedly.... "addendums should be documented as soon as possible and, while there is no official time limit, the entry becomes less credible and reliable with the passage of time" (a legal aspect).
Physician would also need to identify the new entry as an “ addendum” or "late entry" and reference the original entry AND, use the current date and time on the addendum entry.
Hope that helps!