We recently switched to EMR and I'm need help with understanding who is allowed to add the Dx to the disposition/Clinical Impression. I'm running across charts were the nurses/unit sectaries are adding the dx in the disposition. And I don't think that they should be. My argument is that I do my primary coding from the disposition and I don't think I should be using dx codes that have been provided by a nurse/unit sectary. Also I'm noticing that the dx that are being listed by the nurse/unit sectary are not definitive dx's.