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Question- Order of headings in consult/H&P - mt

Posted: Aug 26, 2012

I have a couple dictators who dictate impression/plan at the beginning of their reports. This comes through in ASR and so I have been leaving these at the beginning of the report even though it is not the way I was taught to do traditional H&P, consultation reports. I am not on a verbatim account. Also, the client profile does not mention this at all. Is it okay to leave the imp/plan at the top of report, or should I change these?

I leave it - not paid to move all that

[ In Reply To ..]
MModal can do back end formatting if they want it different.

I leave it, also - Nothing has ever been said

[ In Reply To ..]
I have been on my acct for 11 years. One or two doctors always dictate that way, so I leave it.

Definitely leave it as is - Unless instructed specifically otherwise

[ In Reply To ..]
Some of them just do this. It's their style and it's how they want it. When something isn't mentioned the CP or isn't mentioned otherwise in MM rules, etc., we shouldn't change it.

There is no reason to move it - Not just ONE way to format medical reports

[ In Reply To ..]
There is not just "one way" to format H&Ps and consultations, or any other reports. In fact, there isn't any "standard way" at all.

No rule says you have to do it this way or that way. There are different styles that physicians tend to use based on what was suggested in residencies and on what they see locally and like.

Some facilities may ask their providers to do it one way or another. They may provide the MTs with standard heading templates, and the MT may adjust the content to fit or they might not.

If the physician dictates the impression first, that's fine. Unless your account tells you to move it, leave it where it is. Nothing is wrong with it being there.

What school, if you don't mind answering, taught you to there was only one way to do this?

Yes, only one way to do it. The way the facility wants - it done. nm

[ In Reply To ..]
x

Report order - OP

[ In Reply To ..]
Thanks for all your comments.

I don't remember where I got the idea that there had to be a certain order.

The Order of Things - Old MT

[ In Reply To ..]
I think we were all sort of "taught" that the impression goes at the bottom, as it's the most common way of doing things. However, there's nothing written in stone.

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