Health Information Management

Q/A: Requirements for a complete order

APCs Insider, November 16, 2012

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Q: We have a physician’s group with a very basic electronic medical record.  The orders arrive with the exam listed as “MRI” and then the specifics such as body part and with or without contrast will be included down under reason or comment. If we were audited, would this be considered a valid order?

A: To be considered a valid order, several elements must be present:
  • Patient name
  • Date
  • Test name
  • Reason for the test (diagnosis, sign/symptom)
  • Name of ordering provider
  • Authentication by ordering provider
Nothing specifies what format the order must actually be in, and forms are permissible as long as they have all the required information.

 

If the order has a line for “exam” and the physician writes in MRI, then on a separate line, indicates the body part (such as brain) and then whether the exam is to be with or without contrast, this is sufficient for the study being ordered.
 
The order must also contain the reason for the test (diagnosis, sign/symptom, “chief complaint”) to show why the physician is ordering it. The diagnosis information is what supports the medical necessity of the test being performed. The physician’s authentication should be legible; if not, there should be a legible identifier on the order (such as a printed name).
 
If your order contains all the required components described above, then the order would be considered valid.
 
 
Transmittal 327 contains detailed information concerning physician signatures/authentication.
 
 
 
Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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