Some of our physicians do not write on the ER template that they have order a test or given a patient IM injections but it is on the physicians order sheet and signed by the physician. Can we count the ordering etc from the order sheet for the amount and/or complex of data reviewed and ordered or does the physician have to document all of that on the ER template?

Also does anyone know when a patient comes into er for a sprain and in the history it states they have hypertension but hypertension is now treated, do you still count hypertension as a est problem in the dx and treatment options or you only count what they patient comes in for? THanks