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Orthopedic Coding Alert

Reader Question:

Operative Report Alteration

Published on Wed Aug 01, 2001

Question: If my physician fails to mention a procedure in his operative report, can he change it after the fact? Does he have to redictate the entire note?

Kentucky Subscriber


Answer: In the hospital setting, if the physician has not signed off on the transcribed dictation, he or she should redictate the entire note. If the physician has signed off, he or she must dictate an addendum to the operative report. Hospitals may have different policies regarding this issue.
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