Wiki Diagnosis-I have physicians

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sluke9

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I have physicians putting 'per discharge orders' under the Impression/Plan of the note. I was taught that the diagosis determined in the visit must be documented in the actual note itself. I am being told that the signs/symptoms of the HPI is enough to use as a diagnosis. If a patient comes in stating they had a fever 2days ago but don't have one now, am I supposed to use that as the diagnosis of the visit? Thanks for any input!
 
sluke9 said:
I have physicians putting 'per discharge orders' under the Impression/Plan of the note. I was taught that the diagosis determined in the visit must be documented in the actual note itself. I am being told that the signs/symptoms of the HPI is enough to use as a diagnosis. If a patient comes in stating they had a fever 2days ago but don't have one now, am I supposed to use that as the diagnosis of the visit? Thanks for any input!
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No you cannot use a dx from a previous encounter if that dx is no longer present. The provider needs to document the findings or reason for the encounter, if this is a follow up from a previous encounter or hospitalization then use the V 67.- codes for follow up.
 
diagnosis

This isn't anything from a previous encounter. The HPI is documented with current illness they are having. The physician doesn't state a diagnosis in the impression/plan of the note documentation. I am being told that the signs/symptoms in the HPI is sufficient for the final diagnosis documentation in the note. A physician only states 'per discharge orders' under the impression/plan note documentation.
 
sluke9 said:
This isn't anything from a previous encounter. The HPI is documented with current illness they are having. The physician doesn't state a diagnosis in the impression/plan of the note documentation. I am being told that the signs/symptoms in the HPI is sufficient for the final diagnosis documentation in the note. A physician only states 'per discharge orders' under the impression/plan note documentation.
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There should be something in the exam that relates the findings. I would not use a dx from the HPI if it is not reflected in the exam. For instance I had one where the cc was a rash and the HPI reflected the issues regarding the rash, however the exam reported that there were no rashes, no issues or complaints for the skin. Which then makes it impossible to code the dx as a rash. I always look to the exam to reflect the relevant dx for the encounter.
 
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