RE: Diagnosis Management Options

medicalsec

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RE: Diagnosis Management Options

The new problem, additional workup planned (4 Points) under diagnoses and management option is sometimes confusing to me. If our doctor is the actual admitting doctor, but the tests were ordered originally by the ER doctor, would this be considered an additional workup if they were not ordered by the admitting doctor. Often times that questions is the only thing keeping our doctors from going from a moderate to a high complexity category.

I believe that our doctors are often in charge of directing the ER doctors to order certain tests to determine the dx, but it is often hard to determine whether they stepped in after the final diagnoses was known and then admitted the patient.

Thanks,

Dee
 

LindaEV

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I personally would not give credit to the doctor for the tests, unless it is specifically documented that the doctor ordered them.

If your doctor is indeed in charge of "directing" the other staff he should document as such, and then I would allow credit...even if it said "we ordered a ..whatever.... to determine..whatever...."

I think if you are truly having trouble determining who stepped in where, then you shouldn't give credit. The record should be clear.

:)
 

medicalsec

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I appreciate your reply. It certainly sounds reasonable. Sometimes I just need a good sounding board to feel confident in my decisions.

Thanks,


Dee
 
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