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Templates and Dictation

  1. #1
    Question Templates and Dictation
    Medical Coding Books
    I have a doctor that uses templates while he sees the patient and then uses these templates as "notes" when he dictates that evening. Here is my question. When he dictates his Review of System, he is only listing 3 to 4 yet his template is filled out with either negative or positive (with additional comments) for all 10 ROS. He billed a level 5 new patient visit due to some very serious problems this patient was having. Now, we are being hit with a pre-payment audit on this claim. Will the Review of Systems on his template cover the documentation requirements even though his "typed dication" doesn't cover everything? Or, should I tell him to make sure he dictates everything from the template to his actual "typed dictation"?

    Thanks for any input.....

  2. #2
    Louisville, KY
    I cannot tell you how the med. review will be conducted. From a compliance standpoint, it would be prudent to have the dictation and templated record match exactly on every patient; really that is the only way to ensure no questions will be raised.

    Good luck.

  3. #3
    If you send your dictation template in with the dictation, they will probably count that ROS as well.

    In the future, just have him add to the end of the 3 - 4 systems he does dictate, "otherwise ALL other systems are negative."

    This will give his dictation credit for a complete ROS everytime.


  4. #4
    Thank You all.

  5. Smile obgyn templates
    can someone send me a template for ob and gyn

  6. #6
    Milwaukee WI
    Default Reference template
    Instead of "all other systems negative" (which they may or may not be), I would suggest that his dictation include a reference back to the handwritten template.

    example: For full ROS, PFSH please see written notes of dd/mm/yy. Pertinent to today's visit: ......(etc)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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