Chart Audit Question

[tnapora]

Do you give credit for Lab and Xray that was reviewed at the time of the visit, but not documented? Lab and X-ray reports in chart with signature and date on the actual reports themselves, but again, nothing in the progress note.
Thank you!

 

[colleenwade]

In the 1997 guidelines, under Amount or Complexity of Data, one of the documentation guidelines states:
"DG: The review of lab, radiology and/or other diagnostic tests should be documented. A simple notation such as 'WBC elevated' or 'chest x-ray unremarkable' is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results."

 

[rthames052006]

Do you give credit for Lab and Xray that was reviewed at the time of the visit, but not documented? Lab and X-ray reports in chart with signature and date on the actual reports themselves, but again, nothing in the progress note.
Thank you!

Not documented, not done....

 

[member7]

When a third party auditor reviews the chart what is normally looked for is reason for the procedure, a physician's order, a supporting diagnosis, the procedure report, and acknowledgement of that report either in the progress notes or on the report itself.

 

[Erickapz01]

I would only code if it is documented and diagnose by the physician in the progress notes.