Wiki Documentation of Labs ordered

[ktdiamond]

If a provider is stating on his office note to "see orders " under his plan of care and when I go to the orders he has Labs listed here, can I count these towards medical decision making? He does not specifically list what labs he was ordering on the actual note, just statement to see orders.

Thank you!

 

[csperoni]

As long as the orders are part of the medical records, then I believe yes, they could be counted. I will note it's not a best practice to have multiple documents for a single service. Any EMR I've worked with will allow the order to easily be pulled into the note without the need for the provider to document everything twice. For a one off, I would count it and educate the provider for moving forward.