Documentation Help

dsmith06351

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I am auditing a surgeons dictated Consultation note. At this visit it was decided to perform surgery the format that this doctor uses is designed to not have to redo the consultation at the time of surgery. In the header she dictates an admin date. During the plan she states that the surgery is scheduled for the anticipated date and there is a section for the surgeon to make updates with a signature date and time section so she can attest to review the H&P and making any updates if necessary. The note is then signed and there is a dictation date and a transcribed date.

My question is this shouldn't there be a date of service in either the header or in the history section? The surgeon believes that the dictation date would qualify but it seems to unclear to me, I would love to get some input on this and if there is any guidelines that addresses this so I can show her that would be great also,

Thank You
Denise Smith CPC, CEMC
 
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SHOULD be a date of service

She should separately dictate and record a date of service. While the surgeon may ALWAYS dictate right away, there is no way for an auditor to know this. It is not uncommon for a physician to get tied up with other matters and not get all dictations done on the same date as the service was provided.

To be perfectly clear, and "audit-proof" the surgeon should dictate the date of service.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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