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Offic visit and X-ray same day

  1. Question Offic visit and X-ray same day
    Medical Coding Books
    I have a question.. when our doctor sees a patient and performs an x-ray on the same day, can he dictate it on one report or should he do the x-ray results on another report
    Regina S. Blanton

  2. #2
    It has been recommended to us by many chart auditors to place the xray note in a seperate location of the chart titled Reports/Lab/Xrays. Our doctors dictate it in the body of the office note and the transcription service "pulls" it out and places it on its own sheet.


    Date of Service: xx/xx/xxxx

    Radiology Report: Patient name DOB

    Exam: Left knee

    Xray: Standing AP, 30 degree PA, lateral and patellar views of the left knee were obtained. The patient's left knee has significant degenerative change about the medial compartment.

    Doctors name
    Doctors signature


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