I'm not sure if I'm in the best area for this question, but I will start here. I am having to play referee between an E&M Coder and a Clinic Nurse. I am looking for a specific rule or policy regarding documentation for tests such as UA's, glucose testing, and PT/INR's that are performed in the clinical setting. The main question is, does there have to be an actual written order? If not, what is the correct documentation to be done by both the physician and clinic nurse who performs the test?