My administrator just informed me that I need to give our physician my coding worksheet that shows all the codes that I have abstracted from the chart so he can dictate his discharge summary from it. This physician will not do his discharge summaries until 30 days from the patient's discharge and when he does do them they are not even correct. The physician is dictating diagnoses that the patient's does not even have. I do not have a good feeling about this. I work at an Inpatient Geriatric Psychiatric Facility. Any thoughts on this or does anyone know who I can call and get some type of clarification?
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Wiki Is this unethical?
- Thread starter mpete0719
- Start date
mitchellde
True Blue
He has it backwords, we code from his documentation he does not document from our codes! I agree with you on this. If you look in the coding guidelines it states that the importance of complete documentation in the medical recode cannot be over emphasized, because with this documentation it is difficult if not impossible to assign the correct codes.