Wiki History and Physical


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I work in an Ambulatory Surgery Center. We just had an audit done, and they told me that I should be using the H&P when coding. I strictly use the op note to code from for diagnosis and procedure. I have been told at all conferences not to use the H&P, only if the op note does not have a diagnosis. I do use the path report if it references that it was sent to path. Does anyone know of any documentation that I should be using the H&P when coding an op note. To me the diagnosis on the op report are the surgeons finding when the procedure was done, and that should be the final diagnosis. Just wondering what other thoughts are out there. Thanks!
I am with you I have never used an H&P for a diagnosis for an operative procedure. Who did this audit and where is their source for this information? I would be very interested as well.
I agree! I'd be curious as well to know what source(s) the auditor used for this! The H&P would have signs and symptoms. The op report gives your final diagnosis which should be the only codes you use. I'd certainly argue this point!