KIMS
New
When a patient is evaluated in the ER and a T sheet is filled out by a ER nurse and she documents Right Ear Pain. The physician then comes in and evaluates the patient and diagnosis Acute Ear Pain, but does not use laterality ie Right or Left. Can the coding be done as Right ear pain using the T sheet notes of the Nurse. When the physician signs the ER documentation are the T sheet nurses notes then continued part of the document. Thank you