I am trying to code an encounter for a patient who came in for pre-op clearance. The provider did not fill out our progress note, he wrote "see H&P which is a separate form from the surgery center itself that he filled out. He documented a few conditions with a plan such as stable or controlled. When I received the encounter, he also circled some codes that were on the H&P as personal medical history. He did document meds as well but did not link them to the specific conditions. So I guess my question would be can I code from the history without having a plan specifically linked to the condition? I know what medications go with certain conditions, but not being clinical, am I allowed to do that? Any help would be greatly appreciated!