Reader Question:
Document Errors in Records
Published on Sun Jul 08, 2012
Question: The physician saw several patients on the same day with sore throat symptoms. His nurse performed in-office strep tests on each patient. She inadvertently performed a strep test on an additional patient who did not require one. Obviously, we won't charge the patient for the test. How do we address it in the documentation? Answer: Document in both the physician's note and the order for the strep test that the testing was done in error, so the situation is already noted if questions arise. Whoever ordered the test (whether the physician or nurse) should make a notation such as "Entered in error, wrong patient, patient will not be charged."
