Wiki Physical Exam Documentation

[tuttywilson]

Can I capture a dx if stated in the physical exam since it is physician stated, or does it need to be in the Assessment/Plan? Example; morbid obesity, cachexia, etc.? I am getting conflicting answers and appreciate your feedback on the matter.

 

[jkyles]

Hi there, I know coding experts who say that's how it should be done. Certainly it is easier for everyone if providers stick to a certain template when they document but it isn't a rule or meant to be taken as rule. If the diagnosis is clearly stated and not contradicted elsewhere in the chart then you're fine.

 

[csperoni]

That aligns with my personal opinion, but my employer wants the provider to state the diagnosis (words and/or codes) in the assessment and plan section. For example, it could be an incidental finding that is not being treated or evaluated, therefore should not be coded. This is definitely a grey area and having the clinician put it in assessment/plan makes it black and white.

 

[rachaelwilleford]

That aligns with my personal opinion, but my employer wants the provider to state the diagnosis (words and/or codes) in the assessment and plan section. For example, it could be an incidental finding that is not being treated or evaluated, therefore should not be coded. This is definitely a grey area and having the clinician put it in assessment/plan makes it black and white.

If it's in the assessment and plan, the provider needs to be assessing that condition, treating it, or it needs to be impacting treatment of another condition. I'd agree with your take on it.