Hema Occults done by ED physicians

At our facility, as provider-performed occult blood testing is generally part of an order set/power plan, it is automatically ordered as a rule.  We have dedicated POC electronic forms within the EMR to capture the result, along with lot#, QC and who did the test.  That information is pulled automatically to both the lab result tab (immediately) and to an audit form the next day (autogenerated) which serves to both audit the entered results and creates a list for manual charge entry into the EMR (Cerner).

It is OK for a provider-performed test to be incorporated into treatment notes and not dedicated lab space but there is still a requirement to record all the appropriate information.  It was a struggle to get them to use the form at first, but they are pretty consistent now.  Of course if they don't use it, I have no way of knowing without searching the entire chart (I don't).

If your hospital, not necessarily the laboratory, is using Epic then the Clinical staff must enter manually performed tests into PowerForm. I am sure that there are similar resulting options in the other major EMR software programs. Once the result is verified the charge is posted.  Yes it is a regulation that all tests must be entered into the patient's EMR.  If it is a POL, which does not use a computer based records system, then there must be some form of documentation which also includes the results of the card's QC results.  It is not acceptable for the provider to just document that the occult blood was positive or negative as though it were just a random comment.  Also, if the provider documents the test results, a charge must accompany this as well.  Ignoring charges can result in Medicare/Medicaid inspections and possible insurance fraud charges, as CMS can audit and ask "why did you charge this patient but not this patient?"