MAY 19, 2016
How to Document an Order for Testing Services
Question: What is the best way to document testing performed the same day on new patients? For established patients, the order is typically on the previous visit.
Answer: For any tests delegated to ancillary staff, you need to document an order in the chart. It should indicate 1) the test(s) to be performed, 2) in which eye(s), and 3) the medical necessity. The physician should also provide the interpretation and report. If the physician performs the test, this should be easily inferred along with the findings. Document all this in the current note when services are performed the same day. You do not handle it any differently whether the patient is established or new.