Menu

Blog Posts

pathology diagnoses

Documentation Tip of the Week: Radiology, Pathology and Lab Results

Posted on Wed, Oct 14, 2015
Documentation Tip of the Week: Radiology, Pathology and Lab Results

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

Did You Know?

Radiology reports, pathology diagnoses and laboratory results are not coded unless the clinician documents their clinical significance in the medical record.



Remember, hospital documentation can include “possible, probable or suspected” diagnoses.



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

Share