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Wiki Dx code from HPI/ROS

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Tonyj

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When coding notes, if the MD doesn't include diagnoses from the HPI and/or ROS in the Impression/Plan is it justifiable to include them?
 
If the provider only mentions the diagnosis my question is how did he treat the diagnosis?
did he identify the status; did he/she discuss any type of plan; did he/she examine the relavant portion indicated. If one only mentions a disease and did nothing about it then the record speaks for itself--nothing was done - nothing is given.
 
Gwendolyn Darrell said:
If the provider only mentions the diagnosis my question is how did he treat the diagnosis?
did he identify the status; did he/she discuss any type of plan; did he/she examine the relavant portion indicated. If one only mentions a disease and did nothing about it then the record speaks for itself--nothing was done - nothing is given.
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e.g. Pt being seen for f/u cancer. HPI/ROS oral thrush given rx by pcp, hypertension given meds by other md. Impression/Plan: Hold chemo, complete course of rx, see other md for hypertension.
 
In this case, I guess we should code cancer primary dx and you can add others as secondary dx because cancer is what doc is following up and treating. I guess doc is an oncologist too.

HTH.
 
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