I need some help settling a disagreement in my office.
I have a surgeon that periodically forgets to dictate his assistants on his operative reports. I have had them added to the op-notes through transcription before. Now transcription will not add them. They are requiring the physicians to dictate an addendum to their operative reports. The facility always has their intra-operative report and the assistants are documented in that. I am being told to not have an addendum dictated and to go off the intra-operative report.
My question in this, is that this is the facilities medical record, not the physicians. Can I use that as the physicians documentation?
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