FTessaBartels
Guest
Diagnosis is NOT same as chief complaint
The chief complaint is the problem bringing the patient to the healthcare provider - in the patient's own words.
The diagnosis is arrived at by the provider after examining the patient and reviewing the history.
So
Chief complaint - sore on butt
Diagnosis - abcess on buttock, probably MRSA infection
(of course you wouldn't be able to code the "probable" but that's how I see them written all the time).
-OR-
Chief complaint - fell off swings, hurt wrist
Diagnosis - Right distal radius fracture
Hope that helps.
F Tessa Bartels, CPC, CEMC
The chief complaint is the problem bringing the patient to the healthcare provider - in the patient's own words.
The diagnosis is arrived at by the provider after examining the patient and reviewing the history.
So
Chief complaint - sore on butt
Diagnosis - abcess on buttock, probably MRSA infection
(of course you wouldn't be able to code the "probable" but that's how I see them written all the time).
-OR-
Chief complaint - fell off swings, hurt wrist
Diagnosis - Right distal radius fracture
Hope that helps.
F Tessa Bartels, CPC, CEMC
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