Wiki Regarding dictation

[rjenn86]

I have a question regarding dictation as I have doctors who think they can add dx in the assessment without having any supporting documentation other than the dx. So in this case pt has a foot ulcer, and that is all that is talked about regarding the dx. However, our doc chose to add in other dx such as charcot disease, and venous insufficiency. Doesn't the doctor have to dictate something about those 2 problems as well such as in the physical exam, before just adding them into the assessment?? Please help! Thank you

 

[mitchellde]

Yes, you cannot just pull a DX out at the last second with no mention of it in the body of the note. We code the reason for the encounter plus any other conditions that are managed, controlled, or treated, or that can affect the treatment of the current problem. So somewhere in the note there must be evidence of this.