Wiki Finding diagnosis on medical record

[jkjohnson@uams.edu]

I work for a Radiation Oncology clinic at a large hospital, so almost all of our patients come from the Cancer Center in our hospital. Most of the time their path results, imaging results and oncology physician visits are available to us in the hospitals EMR, and are scanned into our clinic's EMR, which is considered to be our legal record. If our physician does not document a diagnosis with sufficient specificity during the E/M visit, is it appropriate to use the results of previous tests, or the record of the oncologist?