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Doctors using their own templates jeopardize patient care - Angie

Posted: Dec 11, 2012

I don't know about the rest of you but I have very few male doctors who are careful enough to adequately edit normal templates to meet the patient's particular criteria. It's gets pretty time consuming to do it myself, especially when we are not qualified to do this in every instance. Female doctors almost always attend to these details. NPs, PAs do a much better job than the male docs, but few male docs either care, feel it is their job, or take responsibility for this editing. I'm curious how many others have the same experience I do with doctor's templates. I also find it amusing when a doctor says "use MY normal template for ....." and no such template exists, it's a shared template.

Editing templates - MT

[ In Reply To ..]
If the dictator doesn't edit it properly, it's probably best to leave it alone. I'm not sure that we are supposed to edit on our own. It's quite normal for dictators to ask to use a template for, say, a physical exam, but they may only edit the abdominal exam portion or nothing at all. I don't personally feel it's my job to make the decision to edit this template if it doesn't match the rest of the report. The dictator can either catch it before he/she signs it and make necessary changes or sign off on it as is. It's their dictation/report.

Not my experience - oldiebutgoodie

[ In Reply To ..]
I have several male physicians who uses templates. One actually dictates to use "number xxx" and I fill in the blanks for each patient encounter.

One of my docs composed them himself and I inherited them from the previous transcriptionist.

My third one changes up his templates a couple of times a year when changes in coding dictate the need (he actually tells me why he is making the change and I update his template for future use).

On my hospital accounts, I use the template and if no changes are dictated, I make no changes.

Thanks to both for your input. (sm) - Angie

[ In Reply To ..]
It concerns me, not only because it affects patient care, but I could see it coming back on me for not either making sure it is correct for the particular patient, or taking the time to have to email the supervisor to contact the client, blah blah blah. These things happen so often, demographic errors, etc. it gets pretty time consuming to have to correspond on each one. Thanks for your input though. I'm glad that isn't your experience. :o)

Followup - MT

[ In Reply To ..]
You should not feel concerned about it. Unless you have been specifically instructed to edit outside of what the dictator states, it is not your responsibility or right to make those changes. If there are discrepancies occasionally, such as HPI says diabetes and then PMH says no diabetes, hold it for QA. If a particular dictator continues to dictate these types of discrepancies, bring it to your supervisor's attention. But, again, it is not your responsibility or right to make changes that are not dictated. If their mistakes affect patient care, that is the responsibility of the person who owns and signs the report. We are not healthcare providers. We simply document what healthcare providers want documented.

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