Dictation

Is this a requirement? We have a standard form we use for office visits that have all the requirements on it for the physician to fill out.

re: Dictation

What you probably have is a form that someone made up and was approved as a standard office form for your practice. It includes what elements are required by CPT® guidelines for E/M services. It is like a cheat sheet-a quick easy reference your office utilizes. It is a visual cue that helps keep whomever needs to document the patient's visit to stay on track and make sure they include vital information needed to be eligible for payment for the services performed and entails exactly what happened during the visit. I have seen a lot of handwritten office notes. They are alot more time consuming when trying to pick out the elements to see if the level of service that the documentation meets. There is alot more room for human error and could cost the practice more money in lost revenue. The handwritten notes usually include some type of organization to them also.

Without this form anyone who needs to document, code, bill and audit the record will need to continuously look up the CPT® guidelines for each and every patient encounter. This form is truly cost effective and a ton less time consuming.