lillianivy
Networker
Our new EMR now populates the ICD-9/ICD-10 codes to the actual record(That the physician chooses). So the physicians say they will no longer need to document the diagnosis under the plan/assessment. This makes me nervous. Is that sufficient documentation? Plus with ICD-10 and them not knowing all the guidelines I am nervous of them selecting the wrong one. And if they don't document in addition to the selection how am I to know if it is correct or incorrect.
For an auditor reviewing this record, is this ok? They wouldn't need to physically document the diagnosis in addition to the code?
Thank you,
Lydia
For an auditor reviewing this record, is this ok? They wouldn't need to physically document the diagnosis in addition to the code?
Thank you,
Lydia