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Question about placement of BCH and should it be typed

May 18, 2021 - Posted by kenetriaguy in Transcription

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I have a question. As  a transcriptionist I have been instructed since the beginning to NOT document anything that is not documented or stated in the correct place. I am transcribing a report that has a brief clinical history space, but nothing is in it. However, the information is in the above location. Would it not be fraudulent to put the information in the space since it has NOT been documented properly?

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