I have a specific provider who at times doesn't like to use a SOAP template or put a final diagnosis, I can make assumption as to why the patient is there or I can capture signs and symptoms, but for prenatal care, is it okay to make assumption here and capture O code for encounter of pregnancy supervision? or is it best practice to have the provider document final diagnosis?
Patient is 42 yrs old, 38 weeks. G2, P0
![1695396422310.png 1695396422310.png](https://www.aapc.com/discuss/data/attachments/6/6487-09dbf805f1a02c5960b5a5ee5c18c625.jpg)
Patient is 42 yrs old, 38 weeks. G2, P0
![1695396422310.png 1695396422310.png](https://www.aapc.com/discuss/data/attachments/6/6487-09dbf805f1a02c5960b5a5ee5c18c625.jpg)