• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Finding diagnosis on medical record

Messages
2
Location
Bryant, AR
Best answers
0
I work for a Radiation Oncology clinic at a large hospital, so almost all of our patients come from the Cancer Center in our hospital. Most of the time their path results, imaging results and oncology physician visits are available to us in the hospitals EMR, and are scanned into our clinic's EMR, which is considered to be our legal record. If our physician does not document a diagnosis with sufficient specificity during the E/M visit, is it appropriate to use the results of previous tests, or the record of the oncologist?
 
Top