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Wiki Documentation requirements for 'reviewing' EKG's, etc.

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purplescarf23

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Good morning members. I am searching for information on what must be documented to prove a provider 'reviewed' an EKG, lab, X-ray etc. My company is trying to establish guidelines for our providers and I'm struggling to find a 'guideline' on what should be documented to support this. We have many providers just putting DATA Reviewed: EKG Reviewed: Yes, Imaging Reviewed/Ordered: Yes, Labs Reviewed/Ordered: Yes. The coders in my group as well as the manager do not think this is sufficient as we have no clue what was reviewed, when or if they just carried it over from a previous note. NO dates, no summary of what was reviewed or anything. Any suggestions on sources for guidelines is greatly appreciated. Thank you

Kelsey, CPC, CEMC
 
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