# Redictated Physician Notes



## Love Coding! (Apr 28, 2008)

I have a physician that I work with that is hesitant on redictating his notes if he is missing a diagnosis or a minor detail on what he did during the visit.  He thinks it is ok to draw a line over the discrepancy, date and sign the dictation.  Is this ok?  Or does he have to redictate the whole visit, making the correction where it is needed?  I need to show this to him.  As an FYI, any discrepancy or error that I see in any of my physicians' dictation I make them redictate.... Am I at fault?

Help!

Thanks, 

dscoder74


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## Susan (Apr 28, 2008)

While I applaud your strict adherence to documentation and coding meeting the requirements, I would have to side with the physician on this particular point.  If the physician or coder finds a discrepancy in the dictation it is allowable for the physician to put a single line through what is incorrect along with the date and initials.  If something was inadvertently left out of the dictation then to dictate an addendum would be appropriate.  I certainly prefer to have clean dictation, but there are times when this just does not happen.  When you have the physician re-dictate the entire note do you have them make mention that this is a "correction" or amended dictation?

When I have a situation where the dictation does not match, I print a copy of the original dictation for my physicians and ask them to dictate the addendum.  It takes up less of their time then having to re-dictate the entire visit.

I hope that helps even though it might not be what you wanted to hear.  Have a great day.


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## Love Coding! (Apr 29, 2008)

*Thank you - Susan!*



Susan said:


> While I applaud your strict adherence to documentation and coding meeting the requirements, I would have to side with the physician on this particular point.  If the physician or coder finds a discrepancy in the dictation it is allowable for the physician to put a single line through what is incorrect along with the date and initials.  If something was inadvertently left out of the dictation then to dictate an addendum would be appropriate.  I certainly prefer to have clean dictation, but there are times when this just does not happen.  When you have the physician re-dictate the entire note do you have them make mention that this is a "correction" or amended dictation?
> 
> When I have a situation where the dictation does not match, I print a copy of the original dictation for my physicians and ask them to dictate the addendum.  It takes up less of their time then having to re-dictate the entire visit.
> 
> I hope that helps even though it might not be what you wanted to hear.  Have a great day.



Hi Susan,

I want to thank you for your quick reply.  I am still a CPC-A and want to pursue my certification in E/M and this helps alot.  My physicians will also be grateful!

Have a great day!

Denise


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## Love Coding! (Apr 29, 2008)

*Thank you - Susan!*



Susan said:


> While I applaud your strict adherence to documentation and coding meeting the requirements, I would have to side with the physician on this particular point.  If the physician or coder finds a discrepancy in the dictation it is allowable for the physician to put a single line through what is incorrect along with the date and initials.  If something was inadvertently left out of the dictation then to dictate an addendum would be appropriate.  I certainly prefer to have clean dictation, but there are times when this just does not happen.  When you have the physician re-dictate the entire note do you have them make mention that this is a "correction" or amended dictation?
> 
> When I have a situation where the dictation does not match, I print a copy of the original dictation for my physicians and ask them to dictate the addendum.  It takes up less of their time then having to re-dictate the entire visit.
> 
> I hope that helps even though it might not be what you wanted to hear.  Have a great day.



Hi Susan,

I want to thank you for your quick reply.  I am still a CPC-A and want to pursue my certification in E/M and this helps alot.  My physicians will also be grateful!

Have a great day!

Denise


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