Informational diagnoses

CindyWeems

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Do informational dx (such as homeless or noncompliant) count in the Medical Decision Making segment of a chart audit?
 

Chelle-Lynn

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It is my understanding if the informational diagnosis affects the care of the patient (decision making) then yes. Such as if the patient is homeless and unable to properly care for a wound, the physician may make a different decision regarding the follow up care such as refer the to a wound care center.
 
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