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Who can dictate Discharge Summaries - InpRehabMT-Louisiana-RL

Posted: Jun 24, 2014

I was wondering if anyone knows who can legally dictate a discharge summary. I work for an Inpatient Rehab Facility in Louisiana and our Attending Physician will be on vacation for a week and he has fallen behind recently on dictating discharge summaries. I was wondering if we could delegate someone else to dictate these to help us catch up. Does anyone know where I could find any information on this? I have researched for 2 days to no avail.

Thanks :)

Um, this is a forum for medical transcriptionists - we are not legal experts

[ In Reply To ..]
How on earth would we know?

I apologize emensely for interrupting your day - InpRehabMT

[ In Reply To ..]
Thanks.. I know this is a forum for medical transcriptionists. I thought maybe this would have been a situation that someone else has found themselves in, as I am now (as a transcriptionist working in house)

I've been glancing at topics on this site for a few years now for help on other matters and I thought the people here were a little more considerate and not so rude.

Don't take that poster's response personally. - She attacks anyone who - sm

[ In Reply To ..]
comes to this board with an honest question with her "how dare you" replies, which are more off-base with every post she answers. Ignore her rants, and hopefully someone here can answer your question.

who peed in your Cheerios? - NM

[ In Reply To ..]

You are so rude and beyond disgusting with that comment. Pee in Cherios. - Anon

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Keep your nasty comments to yourself. They are disgusting and so are you.

Such an uncalled-for, RUDE response! - What is your problem today?

[ In Reply To ..]
?

You are not a legal expert - Jane

[ In Reply To ..]
and neither am I, but what does it hurt to treat someone decently? Do you need someone to start a Midol drip for you?

dictation - have you tried

[ In Reply To ..]
Have your tried contacting the AAMT head office?

see if you can move this post to the coding board - ICManiac

[ In Reply To ..]
A coder or coder/analyst should know the answer to your question. Have you asked a coder onsite where you work? It varies depending on the type of facility. I know what it is for alcohol/drug abuse rehab, but I think it is different for a physical therapy licensed facility.

Thanks - InpRehabMT

[ In Reply To ..]
Thanks for your help! I will try that.

Wait! Wait! I know! I know! - Emissary from Coding

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There is no "law" on that. Dictating for someone else is, essentially, "scribing" for them. Anyone can do it ... you, me, a nurse, a scribe, a PA. That is because the physician takes responsibility when he signs the report. The person who dictates or scribes should just mention at the end that the report was dictated by or scribed by them.

The only hitch would be if your facility had a policy prohibiting it. Check that and, if there is no problem there, you can help the doc out. If you do it, it would be scribing. Rehab is structured enough that you can handle it.

no, not just the facility's policy - credentialing as was mentioned by other poster

[ In Reply To ..]
If the doctor has to sign off on it, then a signature line for the doc needs to be added. There are places within the chart that might need to be co-signed and dated as well. The "law" that the OP needs to investigate is one of meeting compliance with credentialing or the facility could risk losing their license to accept certain funding (such as Medicaid, Medicare, BC/BS, etc.).

So now that your little fit of knowing it all has passed, I hope you feel more relaxed.

Somebody peed in your Cheerios, too? - Wait Wait

[ In Reply To ..]
First, I said the doctor has to sign it, so of course there will be a signature block. Nothing I said implied otherwise.

Second, the credentialing is on the head of the attending and should be addressed by facility policy. That is why I mentioned the faciity policy.

Third, CMS permits scribing.

Please note that there is a difference between a law and rules or regulations.

Contact the Director of Health Information Management in the facility. - Fran

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In our facility you have to be credentialed in the med staff office to dictate.

discharge summary - missbarb

[ In Reply To ..]
Physician liason

Dictating for physician - Do not do it

[ In Reply To ..]
Legally, it has to be the attending physician, PA or ARNP. Even in facilities where the residents and interns dictate, the attending has to cosign their notes. Would you be comfortable knowing enough about the patient's condition and care to dictate something that would be a legal document? If the physician has fallen behind, that is not your problem. Stop babysitting and let him take responsibility or suffer the consequences.

Just a note - Nick

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In the law, there is something called "the Captain of the Ship." This means that the attending (or the chief surgeon in a surgical procedure--the doctrine itself started out as primarily a surgical application and adaptation of the "Borrowed Servant" doctrine, but anyway, he or she is deemed to be the one in charge and on whose shoulders the final responsibility falls). If a PA, NP, etc. dictates it and later the "porridge" hits the fan, you can bet that the attending, i.e., "the captain of the ship" will be named in the lawsuit, and not only because attendings generally have deeper pockets than do PAs, NPs, etc. I have seen several cases go to court based on the "Captain of the Ship," one where the physician was not even in the room when the incident happened but because (in the parlance of the law) "he knew or should have known that.....blah, blah, blah." Here is a reference: http://en.wikipedia.org/wiki/Captain_of_the_ship_doctrine

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