jbrashear
Guest
Hello Everyone,
My providers use an EHR in their practice and they often do the following:
Instead of writing a sentence stating, "strep screen done today" or something similar, they add the diagnosis code to the note, list updated meds for that problem, then place "orders". Then they click the procedure code for that order. It usually looks something like this:
Problem #1: Pharyngitis, Streptococcal (ICD-034.0)
Updated medication list for this problem includes:
Motrin 800 mg tablets... one po tid prn pain
Orders:
Strep Screen (87880)
Bicillin CR 100,000 (J0561)
99213 Est Level III (99213)
This is all I get in the way of documentation for the order of a lab test. Would the above method of documentation for an ordered lab pass an audit?
Thank you,
Janice Brashear, CPC
My providers use an EHR in their practice and they often do the following:
Instead of writing a sentence stating, "strep screen done today" or something similar, they add the diagnosis code to the note, list updated meds for that problem, then place "orders". Then they click the procedure code for that order. It usually looks something like this:
Problem #1: Pharyngitis, Streptococcal (ICD-034.0)
Updated medication list for this problem includes:
Motrin 800 mg tablets... one po tid prn pain
Orders:
Strep Screen (87880)
Bicillin CR 100,000 (J0561)
99213 Est Level III (99213)
This is all I get in the way of documentation for the order of a lab test. Would the above method of documentation for an ordered lab pass an audit?
Thank you,
Janice Brashear, CPC