Wiki Documentation requirements for an Order

[AKAJBART]

Can someone please point me towards what is needed on every Order, whether it's for a drug, procedure, radiology test, etc..

Our Dr. runs a Family Practice & Urgent Care Center, and orders a lot of Radiology to be done in the office. He's the ordering, Rendering and Supervising Physician.

I want to make sure that he is Compliant with having all of the necessary info listed on his Orders.

 

[MarcusM]

“Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Section 1862 of the Social Security Act stipulates that payment can only be made for care that is reasonable and necessary.”

“Medical records chronologically report the care a patient received and are used to record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s health care over time. Diagnostic statements must be justified by clinical evidence, tests results and treatment rendered during the encounter for care. Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to:
• validate the site of service;
• the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided;
• and/or that services furnished have been accurately reported.”

“The documentation of each patient encounter should include among other things:
• Reason for the encounter and relevant history, physical examination, findings, and prior diagnostic test results;
• Assessment, clinical impression, or diagnosis;
• Medical plan of care; and
• Date and legible identity of the observer.”