Rncoder
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I code for an ER... if a patient comes in with chestpain or another symptom that would lead the nurse to put the patient on a cardiac monitor...and the nurse documents that the monitor was on and notesd the heart rhythm....but, the doctor did not specifically order "cardiac monitoring" can i still charge that a cardiac monitor was on (for those that use protocaols, this would be that no protocol was ordered as well ). thanks. I LOVE having all these questions i have had answered. You guys are so smart. Thanks for putting up with my easy questions!!