I have a question regarding I/R, I am noticing a pattern with our physicians that when they indicate a reason for the test they are writing something like this.

Reason for Test – H40.1232 – low-tension glaucoma, bilateral moderate stage, Monitor for progression.

Reason for Test – H40.013 – Open-Angle with borderline findings, low risk, Monitor for progression

I am trying to teach them the correct way to document a chart, all the other pieces of the I/R are good, I am just not sure if something like this is okay.

Any help and/or feedback would be greatly appreciated.

laura