# Chart Audit Question



## tnapora (Jun 20, 2008)

Do you give credit for Lab and Xray that was reviewed at the time of the visit, but not documented?  Lab and X-ray reports in chart with signature and date on the actual reports themselves, but again, nothing in the progress note.
Thank you!


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## colleenwade (Jun 20, 2008)

In the 1997 guidelines, under Amount or Complexity of Data, one of the documentation guidelines states:
"DG: The review of lab, radiology and/or other diagnostic tests should be documented.  A simple notation such as 'WBC elevated' or 'chest x-ray unremarkable' is acceptable.  Alternatively, the review may be documented by initialing and dating the report containing the test results."


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## rthames052006 (Jun 21, 2008)

tnapora said:


> Do you give credit for Lab and Xray that was reviewed at the time of the visit, but not documented?  Lab and X-ray reports in chart with signature and date on the actual reports themselves, but again, nothing in the progress note.
> Thank you!



Not documented, not done....


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## member7 (Jun 21, 2008)

When a third party auditor reviews the chart what is normally looked for is reason for the procedure, a physician's order, a supporting diagnosis, the procedure report, and acknowledgement of that report either in the progress notes or on the report itself.


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## eRicK@ (Jun 21, 2008)

I would only code if it is documented and diagnose by the physician in the progress notes.


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