A community of 30,000 US Transcriptionist serving Medical Transcription Industry
Not sure what to do. Afraid of what a physician is asking me to do. Advice - HELP
Posted: Nov 20, 2010
I have an account with a physician whom had one of his office staff call me yesterday on their cell phone, asking me to "delete" information on a particular patient, certain things in their weekly follow up visit reports. He is being audited by someone, and this sort of freaks me out.
I do not want to alter a dictation that has already been billed to insurance for.
I asked him to send the request to me in writing, so that in the event something would happen, I would have that information. I do not carry liability insurance.
He will not send it in an email or text, what I have requested.
Does this sound fishy to you?
THANKS
Afraid to lose my job for not doing it.
keep a copy of the report before and after editing - for documentation
[ In Reply To ..]it's all you can do.
Is there some reason the office cannot edit the report themselves?
Help - Help
[ In Reply To ..]I haven't personally talked to him myself, but when he calls in a few minutes, I will ask him. I just called him and left a message on his cell that I was not comfortable editing any prior dictations, but would if he sent me the request in writing. I also agree, someone in the office should do it. I work at home. That's another reason I worry and think they are just trying to use a "scapegoat" in the event of someone catching them, meaning ME.
That is totally unethical. We are talking about a - sm
[ In Reply To ..]legal document here. I would not delete anything, just "retype" the report or whatever, date and initial it however it is you do it, and make sure it says it is a "revised" report somewhere. If you yourself keep copies of what you type, make sure you keep both copies. You are correct, I would want something in writing before I made any changes and keep that documentation also to cover yourself.
In a hospital this is not allowed period. If the report and already been signed, all they can do is make an addendum to a report, they cannot go in and physically alter a report.
Ouch, Help. I strongly suspect this action would be illegal - Pragmatist
[ In Reply To ..]no matter how you handled it since you would be a party to this violation, or violations. Thus, you would just be documenting your own crime.
Hopefully, your client has already agreed that special cases should be handled in-office, if at all. You both need to agree that an independent contractor should know nothing about this or any future questionable actions since regulations now confer on both parties an affirmative duty to report violations by the other (such as this case you've published details of).
On the plus side, since learning from experience frequently stinks, others will also learn from your posting. Maybe consider this one a contribution to the public good?
Glad I posted....THANKS guys for your advice - HELP
[ In Reply To ..]Well, I will simply tell him that I can make addendums to the patient's reports, NOT removal of any information.
Thanks!
If you change your mind and do feel you need to follow his instructions - - NYMT
[ In Reply To ..]The best way to protect yourself would be to make a hard copy of both before and after, then mail it to yourself and leave it sealed, which would prove the date at which it was done. You might also put in a letter of explanation in the envelope.
deleting a report - ohmt
[ In Reply To ..]If he wants a new report tell him you will be glad to give him a REVISED report but that it will be marked as such and dated with the date you do the revision. What he does with it after that is up to him.
WOW- - LMJ
[ In Reply To ..]Not only is it unethical, it's illegal to alter the LEGAL medical record once it's been signed.
Please don't encourage an MT to do that!!
Don't do it - LMJ
[ In Reply To ..]You'd be breaking the law and doing it knowingly since you asked for an email for CYA.
Tell him you're sorry, you cannot make the change.
And yes, you might lose your job, but aren't your ethics worth SOMETHING??
Not a fun position to be in, I'm sorry he's been so inconsiderate (and IMO shady) as to do this to you.
Don't do it! - Phoenix
[ In Reply To ..]You could get in so much trouble for that. That is changing a permanent record and could set you up to get sued. Tell them to make the changes but you will not.
I would - cll
[ In Reply To ..]contact a lawyers office and ask them if they can tell you over the phone what to do. I am assuming this is more than a spelling mistake. Is the report electronically signed, if so, it should not be physically able to be changed. The EMR I type in, once electronically signed there is no absolute way to change it, you have to type an addendum report. If you can not get an answer from a lawyer over the phone, call the insurance commissioner in your state, they usually have all the laws on medical records. You do not have to give a name, you can call just asking a question and should be able to get an answer. Good luck and document everything, including when you get the calls from the office and what was said to have your own record, if nothing else for yourself. I have found if you document something right away, you are more likely to get all the details remembered as you might forget something important later on. Good Luck
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