A community of 30,000 US Transcriptionist serving Medical Transcription Industry
Normal Templates - Concerns (sm) - Angie
Posted: Nov 30, 2012
We are inundated with sloppy dictators, perhaps the ones that can't use VR. We know how much they hate to dictate repetitive ROSs and PEs, thus they love using templates, or paragraphs from previous reports. Does anyone else note a lot of doctor errors in using these methods, i.e. racing through and not changing all the template details? I have found that NPs and female doctors are able to multitask and get this right, but the only males that can do this are the older ones who have a lot of experience. For MDs who are so technically challenged that they can't even master the "PAUSE" command, I think a lot of errors are going to slip through affecting patient care and safety. This is compounded by our inability to communicate directly with the doctors, which I highly doubt the doctors are aware of. The probably have the false security that errors will be called to their attention, yet I think the only concern of the MTSOs is usually production and money.
absolutely - sm
[ In Reply To ..]bilateral pedal pulse exams when patient has one foot; regular rate and rhythm when patient is in a.fib. They often don't pay attention, and I am sure all kinds of errors are entered into reports.
get copies of your own records--it will scare you to death - MTtired
[ In Reply To ..]according to my records I have cervical cancer and a mid abdominal scar from a hysterectomy--neither are true. I have another chart note that says I have no endocrine problems, but under medications I take Levoxyl--which I do. Once you get through the shock of incorrect information the grammer and spelling are just as bad as the content.
What happens when the patient complains about incorrect charges? - Alice
[ In Reply To ..]This is quite interesting to me because I work with these types of templates all the time, and the doc just says "use my standard template" without corrections. I've complained about conflicts between the templates and the patient's symptoms or medical history, but these complaints have been ignored. The MTSOs that I've worked for don't ever want to question anything the doctor says.
For myself, at one time I complained to Medicare about totally erroneous charges for a doctor visit that never occurred. I had never seen him in his office. In reality, he had seen me in the hospital (and charged for it) and then copied the report to make it look like he had seen me in his office on that very same day, with additional charges. I hadn't even spoken with the doctor or anyone on his staff outside of the hospital on that day or any other day. Medicare did investigate, but took the doctor's word for it because he had documented it. When I pursued the complaint further with Medicare, they also claimed that no billing errors had occurred. They basically treated me like an ignorant patient. There were also errors in my medical history on that report. After that, all I did was write to the doctor's office and stated why I would not be returning and also mentioned that I would be sharing the details of my experience with neighbors and family so as to warn them if they should decide to go to this doctor. Sadly, though, most people don't understand and don't really care, and I think that is why these types of practices continue. My aunt and mother will go to any doctor who smiles and treats them with kindness. What he/she charges or what he/she writes in the medical record doesn't matter to them a bit.
So, it seems that Medicare and the federal government are suddenly changing their tune? Does Medicare still claim that the doctors' word is gospel truth? Being that these discrepancies in the medical records are in print, it will be very interesting when these templates come up for investigation and doctors now try to claim that they were simple errors.
That is not an oversight on their part - Ask any coder
[ In Reply To ..]Doctors get paid according to how much work they do for each patient. The evidence supporting that amount of work is in the documentation. It lies in how much info they collected about the HPI, how much PMH, SH, and FH, how many systems they asked about on the ROS, and how many systems they examined or how much detail they noted on the PE.
As a former MT turned coder, I now understand their attraction to using "normals." They are just plopping a complete exam into every note so they can qualify for the highest payments.
When they get an EHR, they suddenly realize they can copy and paste from the last visit, cloning huge amounts of what is basically fraudulent documentation. Try to take away their ability to import all that with one click and they retaliate viciously.
This has now come to the attention of the federal government, which is investigating and wondering if Medicare is being ripped off (uhh, yeah). Doctors suddenly start doing more work when they get EHRs . . . their patients mysteriously get sicker.
The New York Times has had some articles recently. Just google physician documentation, EHR, payments, fraud, and such to find some entertaining reading.
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