Wiki ICD-9 coding and medications

[jbunni342]

When coding a diagnosis in a soap note, does a diagnosis need to be listed for each med given or does it matter? For example: Assessment says: DM II, HTN, Meds given are: Metformin, Lisnopril, & Ambien, so not diagnosis for the Ambien. Does this matter?
Thanks!

 

[mitchellde]

Not really, sometimes providers use combinations of medications for one single diagnosis. It may not be obvious to the one reading the note exactly what is being treated. Perhaps the provider is using the lesion peril and the ambien together for the HTN, there is no way for you to know and without something being written in the exam portion of the note with respect to a different need for the ambien , it is not important that you know.