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resident physician - concerned mt

Posted: Nov 26, 2010

I have alway been told when in doubt, leave a blank.

Resident did not give attending physician's name. There was a doctor's name in the hearder as attending, but I was not sure so I left the attending line blank at the bottom of the report. My boss calls me and tell s me to go on a limb and guess in the future. I do not like those ethics because it leaves me up for problems in the future.

Comments welcomed.

I wouldn't guess - MTINND

[ In Reply To ..]
If I am UNSURE I leave a blank. Check the client profile for directions in this regard, they sometimes spell it out for you on what they want you to do in that scenario.

I wouldn't guess, because it then becomes my work on the line. Can you leave a QA marker and explain that the MD name was not given in your job?

I was always taught, know exactly what you are doing, or leave a blank. Never guess. Never.

That's just how I was taught, and how I handle it.

No way can you ethically guess in my - sm

[ In Reply To ..]
opinion. There are always docs on call for other docs and where I work, unless specifically specified by teh resident, PA, etc. dictating we do not guess, even though sometimes it is pretty clear in the dictation. Never guess!! Remember, you are transcribing a legal document.

At least she didn't tell you to guess about a medication - Happy MT Robin

[ In Reply To ..]
Although that may be her next option, who knows. If they want you to guess and the header is prepopulated, then when I sent the report in I'd do it with a note just saying that attending wasn't dictated and so you left the info that was there. Document it somehow that you know it may be wrong, but you're leaving it up to the client to check.

Where I work, the prepopulated info isn't necessarily correct, depending on whether it was an appointment specifically for that doctor or if they used a type of recurring appointment that this facility uses. We also have an option to put in the attending spot that comes out as physician not dictated.

Makes you wonder if they'll tell you to guess on this, what else will they tell you to guess on.

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