jenantho15@yahoo.com
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I had a provider ask me if a diagnosis is in the patient's problem list and they pull that into their notes (subjective area) is that sufficient enough to be considered an active diagnosis, versus them typing the diagnosis in the Assessment/Plan portion of their notes.
The example that I have is this:
The protocol is if a diabetic patient comes in to be seen for an ear ache, the MA or nurses are to do a glucose test, every time. Sometimes the provider doesn't talk to the patient about their diabetes. I have been querying the provider stating that the visit is missing a diagnosis for the glucose test. The provider does an addendum stating that the patient has diabetes.
Majority of the time the provider does talk to the patient about their diabetes, but sometimes they don't.
Any help is appreciated!
Thank You,
Jenna, CPC
The example that I have is this:
The protocol is if a diabetic patient comes in to be seen for an ear ache, the MA or nurses are to do a glucose test, every time. Sometimes the provider doesn't talk to the patient about their diabetes. I have been querying the provider stating that the visit is missing a diagnosis for the glucose test. The provider does an addendum stating that the patient has diabetes.
Majority of the time the provider does talk to the patient about their diabetes, but sometimes they don't.
Any help is appreciated!
Thank You,
Jenna, CPC