Wiki Need your opinions

[Colliemom]

So I was hoping for some opinions...

I am auditing a note, and the provider relies heavily on abbreviations to complete her documentation. Under the plan, she wrote the following:

Assessment - Abnormal chest sounds (786.7)
Impression: CXR - has h/o PNA
trend WBC

Do you think a RAC auditor would consider this enough documentation for ordering radiology and blood work? I think she should write what tests she is ordering. Such as "chest x-ray for h/o pneumonia and white blood cell count."

Am I being too picky? Do you think an outside auditor would be fine with the documentation as the provider wrote it above?

 

[trarut]

If the abbreviations are commonly used in the industry, I see no problem with using them since an auditor should be familiar with them.

If the abbreviations are specific to your sub-specialty or your practice, I don't think they should be used in the documentation.

Having said that...if I were an outside auditor, I would not be comfortable giving credit for tests ordered based on that documentation.