Wiki Redictated Physician Notes

[Love Coding!]

I have a physician that I work with that is hesitant on redictating his notes if he is missing a diagnosis or a minor detail on what he did during the visit. He thinks it is ok to draw a line over the discrepancy, date and sign the dictation. Is this ok? Or does he have to redictate the whole visit, making the correction where it is needed? I need to show this to him. As an FYI, any discrepancy or error that I see in any of my physicians' dictation I make them redictate.... Am I at fault?

Help!

Thanks,

dscoder74

 

[Susan]

While I applaud your strict adherence to documentation and coding meeting the requirements, I would have to side with the physician on this particular point. If the physician or coder finds a discrepancy in the dictation it is allowable for the physician to put a single line through what is incorrect along with the date and initials. If something was inadvertently left out of the dictation then to dictate an addendum would be appropriate. I certainly prefer to have clean dictation, but there are times when this just does not happen. When you have the physician re-dictate the entire note do you have them make mention that this is a "correction" or amended dictation?

When I have a situation where the dictation does not match, I print a copy of the original dictation for my physicians and ask them to dictate the addendum. It takes up less of their time then having to re-dictate the entire visit.

I hope that helps even though it might not be what you wanted to hear. Have a great day.

 

[Love Coding!]

Thank you - Susan!

While I applaud your strict adherence to documentation and coding meeting the requirements, I would have to side with the physician on this particular point. If the physician or coder finds a discrepancy in the dictation it is allowable for the physician to put a single line through what is incorrect along with the date and initials. If something was inadvertently left out of the dictation then to dictate an addendum would be appropriate. I certainly prefer to have clean dictation, but there are times when this just does not happen. When you have the physician re-dictate the entire note do you have them make mention that this is a "correction" or amended dictation?

When I have a situation where the dictation does not match, I print a copy of the original dictation for my physicians and ask them to dictate the addendum. It takes up less of their time then having to re-dictate the entire visit.

I hope that helps even though it might not be what you wanted to hear. Have a great day.

Hi Susan,

I want to thank you for your quick reply. I am still a CPC-A and want to pursue my certification in E/M and this helps alot. My physicians will also be grateful!

Have a great day!

Denise

 

[Love Coding!]

Thank you - Susan!

While I applaud your strict adherence to documentation and coding meeting the requirements, I would have to side with the physician on this particular point. If the physician or coder finds a discrepancy in the dictation it is allowable for the physician to put a single line through what is incorrect along with the date and initials. If something was inadvertently left out of the dictation then to dictate an addendum would be appropriate. I certainly prefer to have clean dictation, but there are times when this just does not happen. When you have the physician re-dictate the entire note do you have them make mention that this is a "correction" or amended dictation?

When I have a situation where the dictation does not match, I print a copy of the original dictation for my physicians and ask them to dictate the addendum. It takes up less of their time then having to re-dictate the entire visit.

I hope that helps even though it might not be what you wanted to hear. Have a great day.

Hi Susan,

I want to thank you for your quick reply. I am still a CPC-A and want to pursue my certification in E/M and this helps alot. My physicians will also be grateful!

Have a great day!

Denise