Wiki Report headings

[Jennie Manell]

Hi, I work for a stand alone Radiology office and our doctors also read for other facilities. If a medical report comes to us with the wrong heading on it for the procedure that was actually preformed, but our doctor dictated the correct procedure that was done. Do we legally have to have the whole report changed? Just an FYI the headings are based on how the technologist closed out the procedure when done and they sometimes pick the wrong procedure heading. Thanks for any help.

 

[Skymom]

First, I would do some training with the techs, so they know which heading to choose.

It is not OK to just change or replace a part of a medical record. It is OK, though, to append one with information that is needed to clarify what actually happened.