Documentation Requirements for Stating Dx, Medication, etc.

KStaten

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Charleston, West Virginia
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For documentation purposes, is it required for the doctor to document each of the following:

A) Restate the diagnosis in the plan of care, if it is selected/ documented/listed in the diagnosis section.
B ) Restate the name of the drug / dosage in the plan of care or procedure dictation, if is selected/ documented elsewhere through orders, for example? (Can the doctor just document that an injection was given and then have the medication name / dosage listed elsewhere?)
C ) Restate the name/ number of views for an x-ray, if the number of views are selected/ documented elsewhere in the note through orders, for example?

Thank you.
 
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