# Documentation Requirements



## brandyb82104@gmail.com (Feb 16, 2016)

A patient comes in today for an office visit.  At todays office visit the dr order the patient to return at their convenience for fasting labs work.  Patient returns 2 weeks later for fasting lab work.

What are the documentation requirements for the day that the patient comes back fasting and only see the MA for a lab draw.  Does the MA have to document in the chart that the patient was seen today for labs that were order at a previous visit and what labs were drawn?  I have always been told "if it is not documented it was NOT done!"  Shouldn't they at the very minimum be putting in an orders note with the order for the venipuncture? 

They (MA's) are telling me that they don't need to put in an orders note b/c the labs were already ordered when the patient was here for the office visit, but there is no order for the venipuncture in that progress note.  And that the labs results are proof that we drew them, however, our facility name is nowhere on the labs b/c they are sent to an outside facility to be ran.  So if we were ever to be audited how would we prove that we did in fact draw these labs and not someone else.


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## ntreber (Feb 18, 2016)

in our clinic the MA is required to document the patient came in for blood draw, labs previously ordered by provider on ( date) and where blood was taken from (ie: Left arm / hand )


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