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Wiki Dx documented in the A/P

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nlbarnes

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I have a provider that doesn't document a diagnosis in the A/P. I've asked him to document and he wants the guideline from CMS that this is required. He feels that it can be in any part of the progress note. I cannot find on the CMS website anything to support my request. Can anyone please provide the CMS link?
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He is correct, there is no such requirement. You do not have to mandate the Dx in the assessment and plan; I've seen the diagnosis indicated in the history and/or exam. It's preferred if the Assessment and Plan state the "problem/status/treatment", which helps you determine MDM, but you can abstract a diagnosis from anywhere in the note that is documented/signed by the provider.
 
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