Wiki Need direction on Addendums

[LLRodgers]

Hello,

If you get a report and they do an injection and they did not dictate what was injected or they did x-rays and did not dictate the number of Views and you need this information to code the report, how do you go about it.

If they do an addendum do you add it to the original report is that allowed or do you just add this to the patients file.

Is there a document that I have to do to ask for an addendum?

I am being told different things and want to make sure it is done correctly.

Thank you for the help,

LLR

 

[Orthocoderpgu]

You just ask for the correction is all

If this was done in the clinic, the doc can just go in and correct the note. How will depend on the software being used.

If this is for ops, the doc usually just dictates an addendum or can just add it himself, again, depending on the software.

For the most part you just need to make the provider aware of the correction is all.

 

[LLRodgers]

I work in an orthopedic office where they do the x-rays in the office

So you are saying that they do not need to dictate an addendum and if we have the software where we can go in and correct the report we can do this.

Also our doctors office will scan the X-Ray order into the patients chart that have the number of reviews on it, can I just go in there and find out the information and put it in the report?

I just do not want to get into trouble doing this.

Thank you,
LLR

 

[Orthocoderpgu]

You do not change the documentation, the physician does

Your visits are being documented via software of some kind. I doubt very much your clinic is still using charts.

Your doctor, not you or anyone else, needs to go into their documentation and add anything that they have missed. As far as X-rays, they not only need to document the number of views, but the were taken in the clinic on that day. If your doctors don't do this your going to bill for X-rays that someone has brought in from the hospital or another facility and your clinic will look like you don't know what you are doing. And of course they need to document their impression of what they see on the X-rays as well.

Just because an X-ray was "ordered" does not necessarily mean it was "completed". That "order" is not legal documentation that the X-ray was performed.

All you need to do is let the physician know that the medical record is incomplete. You let the doctor worry about the mechanics of making the correction.