shiloscott
New
Does there need to be documentation some where within the body of the note (ie. CC, HPI, ROS, Exam, previous labs/xray) to support the diagnosis in the assessment & plan? For example--Pt. here for f/u of neck pain. No HPI, No ROS, Exam=constitutional, cardio and resp. A/P says Rash, triamcinolone 1%. DM, stable, CPM. GERD, stable, refills given. Anemia, order labs. Neck pain, stable, pain meds refilled. Is this sufficient enough to include the Rash, DM, GERD and Anemia in the MDM? Thank you