Wiki orders

[ARCPC9491]

The "order" for anything should always be documented in the medical record - typically a progress note or something similiar...the diagnosis on the order should be the same as whats documented in the medical record, so I'm a little confused as to what exactly you are asking? Unless you mean like a copy of the script/lab slip/imaging requisition .. you wouldn't need to make a copy of those, they go with the patient, the "order" should be in the record anyway (assessment/plan) and once the test/lab/whatever is complete a copy of these should been in the record to support the service.

 

[hunters]

I may have the same type of question that you have and I've actually started a thread of my own and then saw your question: I have where the MD used an EMR template to order several lab tests but it doesn't state next to each test the diagnosis or reason for the each test -- and in his dictated assessment/plan -- he gives the list of diagnosis but does not state there that he is even ordering a test. So there isn't anything to tell me specifically which diagnosis he is ordering each test for. The patient does have payable diagnoses for the test -- so am I allowed to link them myself or is the Dr. required to state the diagnosis/reason for each test and I code from that only??

 

[rthames052006]

I may have the same type of question that you have and I've actually started a thread of my own and then saw your question: I have where the MD used an EMR template to order several lab tests but it doesn't state next to each test the diagnosis or reason for the each test -- and in his dictated assessment/plan -- he gives the list of diagnosis but does not state there that he is even ordering a test. So there isn't anything to tell me specifically which diagnosis he is ordering each test for. The patient does have payable diagnoses for the test -- so am I allowed to link them myself or is the Dr. required to state the diagnosis/reason for each test and I code from that only??

Although I dont have my cpt/icd-9 book on hand at the moment the rationale for ordering tests, diagnositic, lab etc... is to be easily inferred in the physicians medical record.

In my office for lab work there is a "flow sheet" which has the test listed with the dx clearly stated for each test being ordered.

Hope this helps!