Wiki Documentation

[soprano]

Does anyone know what kind of documentation would you expect to find for drug testing?
(80101 x multiple units) My providers are saying something minimal like "Drug screen WNL".

Is this enough? Does the documentation need to say how many or what drug classes were being tested?

 

[soprano]

I forgot to add that there are point of care test results which show the results for each drug class tested, but these are kept seperate from the chart note and I'm concerned that if there is a request for medical records for an audit, that these additional records will not be reviewed, as it is not in the normal chart note.

 

[consultingbykristin]

The physician I deal with documents the drug test, how many (e.g. 11 panel drug test) and why he's doing the test. He indicates that it's being done to monitor the patient for use and/or abuse of drugs including prescribed medications.