heatheralayna
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I am having a challenge with some of my physicians. Somewhere along the way one of them has been told (not by me) that if they do a level 3 or less they don't have to dictate inpatient consultations. ??!!
When they provide inpatient consultations they are documenting in the hospital records. Often the referring physician is a hospitalist and they claim they don't have an office to send anything to so why do they have to dictate? The hospital chart is their chart. I am not familiar with exactly how hospitalists prefer documentation, if they have other charts, etc. I do have access to the scanned hospital record.
per CPT guidelines the consult "...must also be documented in the patient's medical record and communicated by written report to the requesting physician... " I have always interpreted that to be dictated. My physician is saying it doesn't SAY dictated; therefore, why can't written suffice?
Does anyone have any recommendations on where I can find any written guidelines that refer to dictation? Has anyone come across this situation or have any guidelines in their office?
Please let me know.![Smile :) :)](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
When they provide inpatient consultations they are documenting in the hospital records. Often the referring physician is a hospitalist and they claim they don't have an office to send anything to so why do they have to dictate? The hospital chart is their chart. I am not familiar with exactly how hospitalists prefer documentation, if they have other charts, etc. I do have access to the scanned hospital record.
per CPT guidelines the consult "...must also be documented in the patient's medical record and communicated by written report to the requesting physician... " I have always interpreted that to be dictated. My physician is saying it doesn't SAY dictated; therefore, why can't written suffice?
Does anyone have any recommendations on where I can find any written guidelines that refer to dictation? Has anyone come across this situation or have any guidelines in their office?
Please let me know.