[Histonet] Kim's question - order documentation

[Martha Ward-Pathology]

I think this is an interesting question.   We frequently get phone calls from clinicians asking for ER, PR, Her2 or sometimes just other IHC stains....just yesterday someone wanted CYK 7 and CYK 20 on a cytology block.   We ask that they either call the pathologist who signed out the case and get them to order the stains, or with something like the breast panel, ask that they fax or email us, stating exactly what they want, the patient demographics and surgical number, etc.   That way at least we have a paper trail for the files should anyone ask why we did the testing.
 
Martha Ward, MT (ASCP) QIHC
Manager

Molecular Diagnostics Lab
Medical Center Boulevard  \  Winston-Salem, NC 27157
p 336.716.2109  \  f 336.716.5890  
mward <@t> wakehealth.edu  
 
 



-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Cheryl
Sent: Tuesday, October 07, 2014 1:14 PM
To: histonet <@t> lists.utsouthwestern.edu
Subject: [Histonet] Kim's question - order documentation

Kim-

Your histonet question may not be as complicated as it might seem. Sometimes it's easier to look at these things backwards.  What is the desired outcome?  If there is an order -- say for a GMS--and it wasn't ordered by one of your pathologists, where did it come from? Can you track back and figure out what doctor ordered it and verify it's a valid request so the testing AND billing is appropriate (not fraudulent). 


When the surgeon or clinician collects the sample at the surgery or in their office, sometimes they want something specific -- say 'evaluate for fungus'.  They may include this in the surgical notes, the office chart -- other places.  His support staff will copy this onto the requisition or somewhere you get the request other than the requisition.  If you keep copies of the req and other incoming documentation-- you've satisfied the requirement--you can track the source of the order.  If you don't, include it in the gross description or notes that are transcribed onto the report so that you have a durable record that you can find (may take a while if it's the archived chart, but you can find it).

This goes back to the requirement that orders can't just come from anyone or for any wild-hair reason-- and you have to be able to substantiate or prove the valid source of an ordered (and billed) test.  

Does that help?

Cheryl
 
Cheryl Kerry, HT(ASCP) 
Full Staff Inc. 
Staffing the AP Lab - one Great Tech at a time.  
281.852.9457 Office
800.756.3309 Phone and Fax
admin <@t> fullstaff.org 
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