TTcpc
Expert
Hello,
I would like to get some opinions/feedback regarding the documentation in an EMR/EHR for lab/radiology review. If a physician pulls over lab/radiology results into their visit note would you count this as 1 point for the review in the MDM section? The thinking behind this is that in order to decide what to pull over into their documentation, they would have had (should have) looked at the report/results. Or, in your opinion should they still have to put a statement that they reviewed it?
If they actually read the test/films (usually rad) then they would put "personally reviewed" and their interpretation in order to receive the 2 points.
Thank you for your opinions!
I would like to get some opinions/feedback regarding the documentation in an EMR/EHR for lab/radiology review. If a physician pulls over lab/radiology results into their visit note would you count this as 1 point for the review in the MDM section? The thinking behind this is that in order to decide what to pull over into their documentation, they would have had (should have) looked at the report/results. Or, in your opinion should they still have to put a statement that they reviewed it?
If they actually read the test/films (usually rad) then they would put "personally reviewed" and their interpretation in order to receive the 2 points.
Thank you for your opinions!