Wiki Active problem codes vs assessment line in EHR visit documentation

[smurray]

As part of our EHR system we have an active problem section that lists the pertinant diagnosis codes for a particular visit. Is this section compliant/sufficient for the care given including xrays or does there need to be an assessment line documenting the pertinant diagnosis.

For example, patient is being seen past the 90 day global for xrays of a total hip. Please reply as soon as possible.

 

[MikeEnos]

From my experience with EHR documentation, the active problem list often includes many more problems than are actually being assessed in today's visit. I would not recommend relying on that, and I wouldn't give credit unless it was addressed in the assessment portion of the note.

 

[nyyankees]

From my experience with EHR documentation, the active problem list often includes many more problems than are actually being assessed in today's visit. I would not recommend relying on that, and I wouldn't give credit unless it was addressed in the assessment portion of the note.

Mike-
Do ALL diagnosis codes that are reported on the claim need to be mentioned in the 'Assessment' section of the note? I have always thought yes but have received conflicting information from my department. Thanks.

 

[MikeEnos]

They have to be mentioned in the note. Typically that would mean the assessment/plan/clinical formulation/MDM portion of the note. Whatever the heading says, doesn't really matter, as long as the reviewer can see that it was considered.