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#107618 - 08/15/08 09:44 AM
Report Change by a Physician
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BCOS
New Member
Registered: 08/15/08
Posts: 2
Loc: FL
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Hello fellow MTs,
I was asked by my client today if "a doctor can make changes to a report after it has been submitted", i.e. lining out in ink and making changes to his/her report OR do the changes have to be "retyped". I'm thinking the report can be changed by the doc as long as he/she initials the change but I just want to verify this. All input to this line of thought is welcome. Thank you very much!
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BKC Medical Transcription
Pediatric Subspecialties
15 years, home-based
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#107737 - 08/15/08 08:03 PM
Re: Report Change by a Physician
[Re: BCOS]
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Redpen
Member
Registered: 12/31/69
Posts: 987
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If I'm reading the question correctly, the report has already been entered in the medical record and signed?
Once the report has been entered in the medical record and signed, it's there forever as a legal document. It cannot be removed, but an error can be lined out/corrected as above. If the error is so large that retyping is necessary, the original version is lined out with a diagonal line, an clear explanation of the error written on it with the physician signature, and both reports remain in the record.
The physician can make changes to the report prior to signing it by retyping and/or by lining out the error in ink, writing in the correction and, if appropriate, an explanation of what was wrong, and signing.
Obviously, the key to avoiding aggravation is to proofread prior to signing!
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Redpen
(The Andrews School)
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#107791 - 08/16/08 08:13 AM
Re: Report Change by a Physician
[Re: Redpen]
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BCOS
New Member
Registered: 08/15/08
Posts: 2
Loc: FL
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Thank you very much for your response. Yes, I totally agree. I also did some research on this for my state of Florida and it basically stated the same thing, adding a time to the line-out, date, and initials of the doc making the "alteration". I agree completely about proof-reading first, but more importantly, in my opinion, some of these docs need to think before they speak! They seem to forget that their "words" are on disk/cassette tape, thank goodness for our (MT) own protection if we were to be challenged! I have to say though, this has not happened in this case; it was just a general question my client had, which may have been more for a personal situation than a professional situation. But again, thank you very much for your response.
_________________________
BKC Medical Transcription
Pediatric Subspecialties
15 years, home-based
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#107831 - 08/16/08 03:46 PM
Re: Report Change by a Physician
[Re: BCOS]
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Redpen
Member
Registered: 12/31/69
Posts: 987
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Oops! I forgot the date and time of the correction! Thanks!
_________________________
Redpen
(The Andrews School)
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