Question: Is it feasible for the impression of an encounter to state only " Doing well." Plan: pt to return 4 weeks for IVIG treatment.
My take is the MD should at least state the diagnosis.
C/C: F/U to ITP 2ndary to lupus.
HPI/brief;
PE/complete;
MDM ?? I'm OK w/risk of complications and data reviewed but number of treatment options or diagnoses???? I'm on the fence with that statement "doing well." there is no mention of ITP nor Lupus in the impression/plan.
To get credit for it under MDM, the condition(s) must be mentioned in the HPI. If the current treatment plan is mentioned specifically, then there's not a need to repeat it in the plan. The doctor does need to acknowledge that he reviewed the treatment plan, though. Are you scoring HPI based off of elements, or chronic conditions?
Here's the documentation guidelines on this:
"DG: For each encounter, an assessment, clinical impression, or diagnosis
should be documented. It may be explicitly stated or implied in
documented decisions regarding management plans and/or further
evaluation.
• For a presenting problem with an established diagnosis the record
should reflect whether the problem is: a) improved, well
controlled, resolving or resolved; or, b) inadequately controlled,
worsening, or failing to change as expected.
• For a presenting problem without an established diagnosis, the
assessment or clinical impression may be stated in the form of
differential diagnoses or as a "possible", "probable", or "rule out"
(R/O) diagnosis.
DG: The initiation of, or changes in, treatment should be documented.
Treatment includes a wide range of management options including patient
instructions, nursing instructions, therapies, and medications.
DG: If referrals are made, consultations requested or advice sought, the record
should indicate to whom or where the referral or consultation is made or
from whom the advice is requested."
