Skin tears noticed by clinician, not physician
I cannot believe I haven't had this problem until now... We are caring for this patient's pressure ulcers and monitoring their ESRD. The RN upon ROC for this patient noted she is caring for skin tears to the right shin and left thigh.
These were not noted by any physician, but the RN did note her care for it in her written order to the referring physician (which is not yet signed).
Can I code these??
The nurse should of notified the physician of the skin tears and the physician would have agreed and given the orders for treatment , therefore I would code them.
I don't code anything i cant find documentation for. When this situation happens to me, i look for that communication between the clinician and the physician. If i cant find it, anyone auditing the chart wont be able to find it either.... and i cant tell you how many times i've asked the clinician where the documentation is and it does not exist, because the convo never happened. I would never assume that the documentation is somewhere, or that the conversation even took place. Dot all you I's and cross all your T's. Or CYA... however you want to think of it. Ask for the same proof any auditor would.
MariaB, I wish I could LOVE your comment!! Took the words right out of my head! Documentation in the record to support is oftentimes MIA.
I would of thought that was a given that she talked with the nurse.Your right never assume As nurses know they need to verify and need to get orders from physician for treatments to be able to write orders and code.