Health Information Management

Q&A: Does physician documentation written in reports equate to an official order?

APCs Insider, October 17, 2008

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Question: There are several tests for which we don't have the usual written orders. However, the physician dictates or writes in his reports that they were done or that he performed them.  Especially if a physician performs the test, does this constitute an order for billing purposes?

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 his operative report: “Did baseline, 10 minutes after removal, 15 minutes after removal, and 25 minutes after removal.” 

Apparently 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 the tests. If the nurse misses the test on that sheet, is the dictated statement that the physician performed the test equivalent to an order?

Answer: A physician’s order is required to ensure that the physician actually requested the service provided. It is a check and balance system.  Without documentation of an order, the provider cannot bill because he or she does not have the legal authority to order or provide the service. In many instances, a physician writes the order and another professional carries it out. If a physician performs the service him or herself (for instance, in the OR), there is no need for a separate order.

If the physician

  • actually does the test or is present when the test is done
  • documents that the test was done
  • documents the results from the test

then it may not be necessary to request separate documentation of the order.  In these instances, as well as the one provided in the example above, the documentation and order become the same entry into the chart.



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