Do you use procedure templates or dictate each note?

[Ligament]

My compliance department is telling me I can no longer use my fill in the blank procedure templates, due to OIG regulations. I think this is total BS. So, the questions are:
1. Do you know whether this is true OIG regulation?
2. Do you use templates or dictate each procedure note?

One method I've though of is to still use my templates, have my MA dictate off the template, and then I sign off on it.

Any ideas MUCH appreciated. Thanks.

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[PMR 4 MSK]

My compliance department is telling me I can no longer use my fill in the blank procedure templates, due to OIG regulations. I think this is total BS. So, the questions are:
1. Do you know whether this is true OIG regulation?
2. Do you use templates or dictate each procedure note?

One method I've though of is to still use my templates, have my MA dictate off the template, and then I sign off on it.

Any ideas MUCH appreciated. Thanks.

I use templates at the ASC. 15 - 30 seconds/dictation. I've heard the same thing about the OIG.

At the hospital I have to dictate full, no templates, but I'd be willing to bet that if the OIG looked at those, they'd acuse me of using templates. My dictations are so ingrained I often go into autopilot dictating. I do everything the exact same, why not dictate it that way. Otherwise, it sounds like the OIG wants us to come up with new phrases for each patient - stoooopid!

 

[Tenesma]

please post OIG regs

 

[lobelsteve]

Transcription has all of my templates. I dictatewhich template to use and if any modifications are needed.

 

[Mister Mxyzptlk]

They want us to use EMR but not op note templates? Somebody introduce their right hand to their left hand please.

 

[Tenesma]

geez, if i couldn't use my procedure templates I would lose a TON of time each day...

 

[ampaphb]

I wrote to both David Vaughn and Linda van Horn regarding the OP's issue. Both were not aware of any "regulation" from the OIG.

Ms. van Horn wrote:

I am not aware of any formal opinion from the OIG with regard to templates. As a general rule, it is important that the documentation be reviewed and changed to match that patients correct information and not just carried forward by the EMR. Default settings can sometimes carry wrong information forward and will set off a red flag to auditors. It is also important that the same words are not copied from one patient to another so it doesn’t look like its cloned.

Do you know where you or your associates received the information regarding an “OIG edict”?
​

Hope that helps, Lig.

 

[Ligament]

I wrote to both David Vaughn and Linda van Horn regarding the OP's issue. Both were not aware of any "regulation" from the OIG.

Ms. van Horn wrote:

I am not aware of any formal opinion from the OIG with regard to templates. As a general rule, it is important that the documentation be reviewed and changed to match that patients correct information and not just carried forward by the EMR. Default settings can sometimes carry wrong information forward and will set off a red flag to auditors. It is also important that the same words are not copied from one patient to another so it doesn’t look like its cloned.

Do you know where you or your associates received the information regarding an “OIG edict”?
​

Hope that helps, Lig.

Paz, thank you sir, I owe you a drink in Vegas. Or a hooker. Or Dave Russo. Or both with Dave Russo.

 

[lobelsteve]

Paz, thank you sir, I owe you a drink in Vegas. Or a hooker. Or Dave Russo. Or both with Dave Russo.

Who is Dave Russo? The guy on these forums is Dr. Usso from Bosnia. That is the guy in Vegas with the drinks and hookers.

Dave Russo? Didn't he play 2nd base for the Phillies in the 80's?