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Dictated Reports

  1. #1
    Default Dictated Reports
    Medical Coding Books
    I was wondering if there are rules to what reports need to be dictated and what ones we can code from handwritten notes. I am particulary curious about Consultations and Discharge Summaries. I thought that as long as we had some form of documentation to support our codes, that would be ok. Thoughts anyone?

  2. #2
    To the best of my knowledge you don't have to dictate anything, ever. It can all be handwritten.

    The only rule I am aware of that is similar to this is actually the exact opposite. It states you must have certain things on the charts within certain time frames and if the note or report is pending transcription you need to put a written note in the chart until the transcribed note is in place. Good example is the op note.

    Laura, CPC

  3. #3
    Thank you so much for all your help. It was very helpful!

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