Feedback from Dr.

Wendy Mcconnell

MRN 203290049

Done by Aishwarya and Edited by Priyanka

L1 Score - 99

Quality Audit - Gayatri - Brief - Score 99.5

Feedback:

Under Plan -

MRI of the right vocal cord lesion was reviewed at length. There was no MRI recently done. He was here to review pathology results from.
Or biopsy. Not sure what that means or where that came from.

Scribe Version:

MRI of right vocal cord lesion (biopsy) reviewed at length, that was negative for invasion but showed severe squamous dysplasia.

Reviewed and discussed MRI of right vocal cord lesion (biopsy) done on 09/07/2022

My Assessment:

EMR Notes shows Abnormal MRI in symptoms and signs section and diagnosis section.

Previous Notes:

During his evaluation with MRI, he was noted for an abnormal finding in his left hypopharynx. He mentions he can feel "something" on the
left side of his throat that has increased in size lately.

On listening to the Audio:

No MRI was reviewed at this visit. Doctor says pathology didnt call it a cancer. They called it severe dsyplasia.

Scribe's Assessment:

I wrote MRI as the report she was reviewing was not clear in the audio thats why i wrote (biopsy) after the heading. I am sure if auditor
retained it then she might have heard the same in audio.

MRN XXXX4784

Under the physical exam, they do not have to write out the tonsil findings. On the comment section, there's a box to click that
automatically puts this into the exam findings.