Wiki Documenting Lab tests reviewed in E/M documentation?

[carlystur]

Good Morning, all!

What would be an example of an ideal way to document lab results at an e/m visit? Or is that even necessary and just specifying that the results were explained to the patient?

 

[ambergremington@gmail.com]

The reading of lab results affects the E/M level, you don't document the results separately, if the provider ordered a lab it is documented then, not when read. Our providers just add "counseling/education/reassurance given" in the medical record.