Friday, September 7, 2007

Afterthoughts and Addenda

Situations often arise in which a physician needs to add an addendum to a previously-dictated report. Or, he may have second thoughts about a patient's office visit and want to add some observations or correct something he has placed in the chart. In such situations it is critical not to attempt to alter the initial record. That must be allowed to stand for medicolegal purposes.

Another complication that arises when a dictating physician wants to add an addendum to a previously-dictated report is that, with a digital dictation system assigning work to mutiple transcriptionists, there is no guarantee that the person who transcribed the initial report will be the person who listens to the doctor dictate the addendum. With transcriptionists working from multiple remote locations, it is not always possible to go back into a document and add a paragraph!

The solution is simple and remarkably straightforward:

  • Begin dictation on a new job and give it the same work type report code as the original.

  • Give the medical transcriptionist the appropriate patient demographics.

  • Dictate: "This is an addendum to my previously-dictated report on this patient."

  • Proceed with any text you wish to add to the patient's medical record. If you are correcting a mistake, simply say so and ask the transcriptionist to put the important words in an underlined and bolded format.

Some doctors become very prissy about not wanting to place an extra piece of paper in a patient's chart. It is much easier and more legally sound to generate an addendum as a separate report than it is to try inserting something into a previously-dictated report and face the potential legal complications which could ensue as a result of your actions.

Next: Visualizing Your Train Of Thought

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