Standing orders

In an OB office, is it necessary for providers to identify specific lab tests ordered, and the rationale (if not easily inferred)? I see many labs performed and billed, but often see no notation in the visit note, or something generic like: "labs pending". Would it be appropriate to state "labs ordered per protocol"?

I don't think so

I often write "DM, HTN, OA stable, check labs and call pt" and then order a bunch of stuff. As long as you link the labs to an appropriate diagnosis there should be no problem.

That being said, documentation for esoteric/expensive tests like Genetic screening for BRCA or other genetic diseases should be more complete both to prove informed consent and in case of insurance audit. Also if you are performing a test more frequently than the standard, such as getting a BMP daily if you just started a diuretic.