Author Topic: Dictation & visit notes  (Read 1194 times)

bkwrmz7

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Dictation & visit notes
« on: February 22, 2010, 03:02:53 PM »
The visit notes gets filled out by the ma, the vitals and cc, does the dr have to write everything down on the visit notes if he uses dictation? i'm confused.

Michele

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Re: Dictation & visit notes
« Reply #1 on: February 22, 2010, 06:34:33 PM »
I'm not sure what you are asking.  If the dr uses dictation, wouldn't the dictation service put the notes in the chart?

Michele
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bkwrmz7

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Re: Dictation & visit notes
« Reply #2 on: February 23, 2010, 09:59:05 AM »
I'm trying to write a reply and I keep confusing myself! I know what I mean but am having trouble getting it out, so let me try again
Pt comes in for their appt. the Dr visits with them, writes notes on the same form that the MA wrote the vitals on etc. Pt leaves.
The written visit notes go along with the superbill to billing for processing.

OR

Pt comes in for their appt. the Dr visits with them, writes notes on the same form that the MA wrote the vitals on etc. Pt leaves.
The written visit notes go along with the superbill to billing for processing.
The Dr then talks about the visit on a tape recorder which then gets to the transcriptionist, who then sends the typed dictation back to the Dr, the dictation is then filed in the Pt's chart

I'm wondering if the Dr can do the dictation in place of the written notes that took place at the time of the visit. I'm thinking the Dr has to write his visit notes to support the coding of the visit, and if he chooses to have dictation of the visit it's just an added bonus type thing.

Is this right?

rdmoore2003

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Re: Dictation & visit notes
« Reply #3 on: February 23, 2010, 02:34:19 PM »
My experience is that you must document as you go to avoid possible incorrect dx, rx, etc.  For the past 4 years I have worked with electronic medical records and it gets the job done during the appointment and nothing should be left out (depending on the program/software, you cannot go forward in an electronic note if you have left a spot blank).  Even the billing software is tied into the records part of the program. 
Regina

Michele

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Re: Dictation & visit notes
« Reply #4 on: February 24, 2010, 01:28:03 PM »
If the dr isn't indicating the code on the sheet, then the billing department may need his notes to determine the services/charges to be billed.  EMR is definitely a great option.  My dr uses it and puts everything in the computer while we're talking.  He used to use the handheld recorder - but the clinic made him switch!

Michele
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