Wiki Dictation of Hospital consults

[catinahill72@yahoo.com]

Is there a rule on whether or not Hospital consultation should be dictated and not just hand written? I have a doctor that covers for our regular doctor and he never dicates the hospital consults, and his handwriting is not the best.

 

[kevbshields]

Obviously if you have legibility problems then it would be preferable that he dictate. However, there is absolutely no compliance or regulatory requirement for a dictated note. So long as the consultation is present in the shared record (or a copy furnished to the requesting party), there is little else to consider.

However, because the service is provided in a hospital, that facility may have a Medical Staff Bylaw that requires something different. Work with the HIM staff to determine if there is any compelling reason he should be dictating these. Likely there is not, in which case try and have a conversation with him about making greater efforts with his penmanship.