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TOPIC: Obtain physician cooperation in documenting orders for outpatient tests

HIM Connection, August 16, 2003

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Every organization should have a strategy for ensuring physician support of documentation requirements in the outpatient setting. This is particularly true in the case of diagnostic testing. When a physician orders a diagnostic test for a patient, that order slip may be the only piece of information and documentation that ties the physician to the patient's record. Therefore, it is imperative that the health care organization develops a group of processes to ensure compliance from the medical staff.

First, every organization should ensure that physicians who are ordering diagnostic tests to be performed at the facility are aware of the type of information the organization needs. The specific elements of a valid physician order are the following:
--Date
--Patient name
--Diagnosis/reason for the test/procedure
--Test/procedure
--Physician signature

In addition physicians should be informed about the concept of medical necessity. This information can be provided via an internet or intranet site easily accessible by the physician and the physician's staff. It could also be made available in small booklets that physicians may carry around in their lab coat pockets. Finally, information regarding ordering of tests can be posted in the physician dictation area and on the units.

Health care organizations can offer specific training sessions to the medical staff on an ongoing basis regarding the ordering of diagnostic tests. In these cases, the organization will most likely need to sandwich the specific information about ordering tests into something more palatable to the physicians-perhaps something more clinical in nature. There must be a reason why a physician would attend such a session, and the hospital can be creative in compiling the agenda items. Obtaining CMEs for the program is another way to entice physicians to attend and stay to the end of the session.

The organization may also consider offering education specifically targeted to the office staff. The office staff may be individuals who actually process orders for diagnostic testing. If not, they are probably in a good position to offer advice to the physician on the way he or she completes the orders.

One of the most simple ways to obtain good information on orders for diagnostic tests is to provide the physicians with a copy of the hospital's standardized order form. The template can be designed in such a way that it is easy for the physician to complete and provide all necessary information to the hospital.

This week's HIM Connection was adapted from an excerpt of, "Guide to Outpatient Clinical Documentation Improvement: The First Step in Revenue Cycle Management," by Ruthann Russo, JD, MPH, RHIT. Go to http://www.hcmarketplace.com/prod.cfm?id=1740&s=EHIMC for more information or to order.

Sincerely,

Lauren McLeod
Executive Editor
lmcleod@hcpro.com

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