Wiki Documenting Date of Service on EHR

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huguezbrian

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I have been stressing to my physicians about dictating the date of service on each medical record. One of our physicians "forgot" to dictate the date of service on 300 of his EHRs. Mind you these charges have not been coded or billed out (which is another issue). He asked me, would it be okay if he just writes the DOS on each EHR and signed it? So my question is, can a physician who dictated his report with out a date of service; write the DOS & sign it? Please advise.

Thank you,

Brian C. Huguez, CPC, CPC-H, MBIC
huguezbrian@yahoo.com
 
Yikes! The whole point of an EHR is to automate things like Dates and electronic signatures. My first thought is to try to get your EHR to make this happen, so you don't have to sweat this out in the future. It sounds like you're dealing with just a dictated note, though, not an EHR system. If so, can your transcription people create templates to force the dictation of a DOS? But if your EHR isn't requiring a DOS...you need to go back to your vendor.

It's definitely appropriate to go back and ammend any note (dictated or otherwise) to add the date of service, but only by the provider who generated the note in the first place. Is he handwriting on a dictated note which is then scanned in? He should probably clarify that it's an ammended note by writing "ammended (today's date), DOS is xx/xx/xx" and then sign. Most EHRs have an ammendment feature that allows for a legal medical record to be updated, because as we know, they all make mistakes, but the provider has to sign off on the ammendment. After ammending 300 records, I sure hope he remembers to include his DOS next time. :rolleyes:

Have a good week.
 
Pam Brooks said:
Yikes! The whole point of an EHR is to automate things like Dates and electronic signatures. My first thought is to try to get your EHR to make this happen, so you don't have to sweat this out in the future. It sounds like you're dealing with just a dictated note, though, not an EHR system. If so, can your transcription people create templates to force the dictation of a DOS? But if your EHR isn't requiring a DOS...you need to go back to your vendor.

It's definitely appropriate to go back and ammend any note (dictated or otherwise) to add the date of service, but only by the provider who generated the note in the first place. Is he handwriting on a dictated note which is then scanned in? He should probably clarify that it's an ammended note by writing "ammended (today's date), DOS is xx/xx/xx" and then sign. Most EHRs have an ammendment feature that allows for a legal medical record to be updated, because as we know, they all make mistakes, but the provider has to sign off on the ammendment. After ammending 300 records, I sure hope he remembers to include his DOS next time. :rolleyes:

Have a good week.
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Thank you. I asked him to go back and ammend all his notes, but like many physicians, he whined about how long it was going to take him. We do have templates set up, but our EHR system 'Meditech" does not pick up the date of service, the MD has to actually say it in his dictation.

Thank you!
 
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