heatherwinters
Expert
If a patient has listed in assessment: 278.00, 401.9, 250.00, 272.4 and 268.9 and on the bottom of the note in the labs ordered section, the doctor circled are CMP, CBC, A1C, Lipid Profile, Urine microalb/creatinine.
Would an auditor match each dx from the assessment to the lab test that was circled at the bottom, or does the doctor have to match them up in his documentation of the visit?
What is considered "easily discernible" in Medical Documentation? Is a list of dx on assessment, then a list of labs circled on the progress note acceptable or does the doctor have to specifically tie each test he orders to the specific matching dx?
Would an auditor match each dx from the assessment to the lab test that was circled at the bottom, or does the doctor have to match them up in his documentation of the visit?
What is considered "easily discernible" in Medical Documentation? Is a list of dx on assessment, then a list of labs circled on the progress note acceptable or does the doctor have to specifically tie each test he orders to the specific matching dx?