Wiki Documentation guidelines for diagnostic testing

[cvand1972]

I don't know what my problem is, but for the past 2 days I have been looking for medical record documentation guidelines specific to diagnostic testing. I am being asked if we have to keep the tracings for the device interrogations or is it enough to document in the note that an interrogation was done. I obviously know that the answer is YES, we have to keep them to provide proof that it was actually done, but I cannot find the guidelines to share with my 20 doctors. Can anyone help? Thank You!

 

[Misty Dawn]

This is from the Heart Rythm Society:

2.8.1. Length of Electrocardiographic Samples
for Storage
It is important that the caregiver(s) providing TTM assessment
be able to refer to a paper copy or computer-archived
copy of the transtelephonic assessment for subsequent care.
The length of the ECG sample saved should be based on the
clinical information that is required (e.g., the points listed
above). It is the experience of personnel trained in TTM that
a carefully selected ECG sample of 6 to 9 seconds can
demonstrate all of the points for each of the categories listed
above (i.e., a 6- to 9-second strip of nonmagnet and 6- to
9-second strip of magnet-applied ECG tracing)

The full artical can be found at www.hrsonline.org

Good luck Misty Sebert CPC, CCC