# final impression vs diagnosis



## loriab (Feb 20, 2014)

hi-  new to ER coding-- can someone please explain difference between final impression vs final diagnosis ? When it says final impression am I correct in assuming I should then code for symptoms??   Thanks


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## Squiabro (Feb 20, 2014)

*Final Impression Vs Diagnosis*

Never assume. Some providers write diagnoses under impression which is part of their documentation format. 

Two common formats are :
History, Exam, Impression, Plan.
History, Exam, Assessment, Plan/Referral.

In both formats, the diagnosis can be found under Impression or Assessment.
If no definitive diagnosis is written, then code for signs and symptoms.

Hope this helps!


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## loriab (Feb 21, 2014)

Thanks for the help!


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## justkissed1 (Feb 22, 2014)

Final impression to me sounds too much like a differential diagnosis which I would not code.  If this is a pattern for your providers I would talk to the director about educating the physicians about documenting a final diagnosis for that visit.  We use an EHR which has a final diagnosis tab where our physicians put their diagnosis.  Sometimes it is symptoms if they are not committed to a more definite diagnosis.


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