bedforak1
Guru
I have a question concerning lab results for an inpatient subsequent visit. Is it appropriate to count that as a bullet point for heme/lymph, etc for the 95 guidelines? Thanks for the clarification.
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Wiki do lab results count for an exam finding
- Thread starter bedforak1
- Start date
Pam Warren
True Blue
Are you talking about exam or history? Lab findings should be reported in data, not as a subjective history element or physical exam. The subjective portion of the history is when the provider questions the patient about what's going on with the presenting problem. It's unlikely that the lab findings are going to come from the patient. As far as including it as a physical exam, a lab test is not a 'hands on' physicial by the rendering provider. I always consider lab tests as data that the provider considered to determine medical decision making.