Health Information Management

Q/A: Does physician documentation in written reports constitute an official order?

APCs Weekly Monitor, October 16, 2009

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Q: We don’t have the usual written orders for several tests. However, physicians dictate or document in their reports that they or someone else performed the tests. Does this constitute an order for billing purposes, especially if a physician performs the test?
 
For example:
  • Hemoccult—The ER physician performs this during the exam, but doesn't write an order for it on the order sheet
  • Parathormone—The surgeon dictates the following in the operative report: “Did baseline, 10 minutes after removal, 15 minutes after removal, and 25 minutes after removal.”
Physicians perform point of care testing in the surgery suite. There is an order sheet and the nurse in the operating room is supposed to record all tests. If the nurse misses the test on that sheet, is the dictated statement that the physician performed the test equivalent to an order?
 
A: A physician’s order is necessary to ensure that the physician actually requested the service provided. It is a check-and-balance system. Without documentation of an order, providers cannot bill because they don’t have legal authority to order or provide the service. Often, a physician writes an order and another clinician performs the necessary task. A separate order is unnecessary when physicians perform the services, for example in the OR.



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