Wiki final impression vs diagnosis

[loriab]

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

 

[Squiabro]

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!

 

[loriab]

Thanks for the help!

 

[justkissed1]

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.