mmelough93
Contributor
I thought the op note had to stand on it's own, but have been advised by management it's okay to use the H&P to determine dx. I work for a big health system and sometimes provider documentation isn't the greatest (for example- many providers will put dx on the op note for colonoscopy as screening, however looking at the H&P they have bleeding or history of polyps which wouldn't be a true screening). Does anyone have any references or resources to support one way or the other?