Wiki final impression vs diagnosis

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loriab

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hi- new to ER coding-- can someone please explain difference between final impression vs final diagnosis ? When it says final impression am I correct in assuming I should then code for symptoms?? Thanks
 
Final Impression Vs Diagnosis

Never assume. Some providers write diagnoses under impression which is part of their documentation format.

Two common formats are :
History, Exam, Impression, Plan.
History, Exam, Assessment, Plan/Referral.

In both formats, the diagnosis can be found under Impression or Assessment.
If no definitive diagnosis is written, then code for signs and symptoms.

Hope this helps!
 
Final impression to me sounds too much like a differential diagnosis which I would not code. If this is a pattern for your providers I would talk to the director about educating the physicians about documenting a final diagnosis for that visit. We use an EHR which has a final diagnosis tab where our physicians put their diagnosis. Sometimes it is symptoms if they are not committed to a more definite diagnosis.
 
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