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Wiki Basic documentation of procedure.

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Patricia Seabolt

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I am auditing services for a provider that does audiometry screenings in the office. The print out of the test is interpreted by the physician however my issue with it is that there is not an indication on the form which patient this is for (name, mrn# etc). The provider feels this is not necessary since the test is scanned into the chart as a packet of information that does include the patient's identifying information on other pages... I cannot for the life of me find specific documentation in guidelines to show him that this needs to be documented on each page of the packet.

Thanks for any information!
Patricia Seabolt, CPC CPMA
 
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