Wiki documentation for labs

[cmoon]

I am looking for opinions from auditors on where the documentation should be for labs. Our providers have a habit of ordering labs with no or insufficient documentation and we are trying to come up with a solution. My supervisor thinks the information should be in the orders tab of the EMR but I think that the note should be able to support the order without having to look in other areas of the chart. Any suggestions?

 

[mssalemny]

From an auditor standpoint I prefer to see it in the office note and supported by the documentation. If it is under the orders tab, the auditor may not even realize that anything was ordered or miss reviewing. Also if you have to send records in for review, not only would you have to print the office notes for the date of service in question, you would also have to make sure that the orders went as well. Hope that helps but there is no steadfast rule.