Diagnosis Coding for inpatient psych patients for the physician

chasarmil

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We have one of our psych docs(Dr. T) that when he rounds on a psych patient in the hospital, instead of documenting the dx, he says as previous. He does this for all his follow up visits.
He is not the only psych doctor that might round on this patient throughout their stay and he might not be the doctor that did the H & P. The discussion between the coders in my department is whether we can code the visit for Dr. T since each record is suppose to stand on their own.

Thanks
 
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I'd say that he needs to state the actual diagnosis. If someone didn't have access to the previous documentation where the DX was listed, then how would they know what it is?
 
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