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Wiki Coder documenting

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jenp2005

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I have a provider insisting that I add diagnosis to his electronic note by guessing according to medication ordered or by looking a a previous note. I know that I can't do that but need to prove to the provider. Any thoughts as to where I can have it spelled out for the doctor.
Thank you.
 
AHA coding clinic 1st quarter 2012 might help.. It states that the physician must document the diagnosis in his own words. Otherwise you might go to the state board of healing arts.
 
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