# "no change"



## deyoung (Apr 14, 2008)

Is it ok for a Dr to put "no change" on the progress note for the Dx or do they have to actual list the Dx? Thx!


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## kbarron (Apr 14, 2008)

*no change*

No change from what? What is the purpose of the visit? What is the chief complaint?. You would need more information to code this visit.


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## member7 (Apr 14, 2008)

I agree.  The diagnosis, rationale, or impression for the visit should be on the note. Correct me if I'm wrong but I believe that documenting the diagnosis or rationale is included in the documentation guidelines for E/M.  Each progress note should stand on it's own.  The diagnoses on the bill or claim form should be supported by what is in the progress note.


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## deyoung (Apr 14, 2008)

Great, that's what I was thinking...the note should stand on it's own. The auditor shouldn't have to search the rest of the chart to figure out the Dx.


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