lsolway
Networker
I review ER charts for both facility and professional leveling. If a physician ordered a diagnostic test (any- lab, CXR, EKG and/or IV) and the results are in the patient's record, but he does not mention of one or more of these in his documentation, can this still be used in the MDM? Or am I to strictly go off his documentation? Also for PMFSH, a lot of physicians write- "see nurses notes" or "unknown if ever smoked" or "never smoker or drug use" (for a child sometimes). Not sure how to count this. Any suggestions on training or education for ER E/M leveling? Thanks
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