Thursday, September 6, 2007

The Hidden Cost of Substandard Dictation

In recent years the Joint Commission has insisted on chart notes and reports being more legible. This means no more scribbling in the chart; no more cryptic notes that can only be understood by the person who wrote them. It means that any notation documenting a patient's care must be able to be understood by anyone else on the patient care team. That includes doctors, nurses, clerks, coders, claims processors and, on occasion, patients and their attorneys.

What this also means is that work which is illegible or substandard is going to get bounced back for revision until it is legible. With payment from third-party carriers depending on the timely submission of complete and acceptable documentation, any rejection of patient documentation as "substandard" can have a sobering effect on cash flow.

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