mhstrauss
True Blue
This question was recently posed to me by our Med Rec Supervisor, and I wanted to get some opinions here. Is there a compliance issue if the doctor misuses gender throughout dictation? For example, patient is female, "female" is checked off in EMR when the account is originally set up, but "he/his/him" is used for the entire office note. I don't remember ever coming across anything that states this is "wrong"...but it definitely makes the doctor--and our clinic--look bad!
Would appreciate any input/opinions/resources anyone may have.
Thanks!!
Would appreciate any input/opinions/resources anyone may have.
Thanks!!