Saturday, September 8, 2007

How Much Is Too Much?

Some doctors have gotten into the habit of dictating the most long-winded reports imaginable for a hospital record so that the text canlater be copied into their personal correspondence. Why? In some cases, the doctor is also a Qualified Medical Examiner (QME) for the Workers' Compensation Appeals Board.

"Overdictating" may create more income for the dictating physician and transcriptionist. It also creates obscenely unnecessary layers of documentationin a patient's chart.

How, then, does one define an appropriate standard of brevityin patient documentation?
  • Brevity of dictation allows a physician to communicate important pieces of information vital to a patient's care in a manner which can easily be understood by the next person who must read the report.
  • Full sentences are recommended in order to avoid cryptic statements that could easily be misconstrued.
  • If information is not really relevant to the patient's care, skip it.
  • It is not necessary to redictate every piece of family and social historythat already appears ten times in a patient's chart.
  • Nor is it necessary to thank the entire medical staff for requesting your services in consultation.
  • Cut to the quick. Get the job done smoothly, efficiently, and with a minimum of "fluff."

There was absolutely no need for doctors to dictate the following information:

"She is on her second marriage now, four years. She has three cats, three dogs, two birds, one swimming pool and is active at home spending a lot of time in a bathing suit."

"Her head throbbed and she felt pain zinging through her body all the way through her soles to the pavement."

Next: Protect Your Credibility

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