Wiki Could I count this as a new dx under MDM?

[alg618]

The provider documents under Subjective:

patient denies hot flashes, has some left arm soreness but may also attribute this to helping her husband get around.

I'm not using this as ROS, but could this be counted as a new problem with no workup if the provider doesn't address this issue under assesment and plan?? The patient has a history of breast cancer is currently on Arimidex.

Thanks!

 

[SWILSON]

Hot flashes

I would not count it as a new Dx, unless the provider documents

 

[a.montaruli@gmail.com]

Unless the diagnosis in question was actually evaluated by the physician this would not count towards the MDM as a new problem.