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Bipolar as a diagnosis - Ex MT, now QA

Posted: Dec 1st, 2018 - 12:01 pm In Reply to: Proofing reports - lmh1

If the provider dictated bipolar disorder as a diagnosis, the MT would not catch that as being an error on proofreading, unless they knew the patient or had the record in front of them. Regardless, it is not up to us to make judgment call in regard to diagnoses; if we caught something like that the report would need to be flagged for the provider to review. That is not a typo, it’s an error in dictation and we cannot remove something like that if that is what the provider said. The doctor is responsible for the content of the note, not the MT. I had an incorrect diagnosis of MRSA entered into my medical record because there is someone else with the same name, different DOB but they didn’t catch it until I was admitted to the hospital and was asked about it. I also had an IME where the examiner made some false statements that I found when I reviewed the report. In both cases I don’t recall it being that difficult to have the corrections made, but I do recall submitting written requests. It’s definitely good to review your records periodically and as MTs it’s good to proofread, but it is not our job to correct diagnoses that are incorrectly dictated.

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