Laterality

JCampbell

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If a provider states in the objective "great toe" but then states in the assessment "cellulitus of toe" is it appropriate to ask that they clarify by putting "great toe" in the assessment?

Also, if a nurse states in their intake where the cellulitus is located, is it necessary for the provider to state the locality in the assessment?

I think in both instances that it does need to be stated, but I do not want to ask for more from the provider if it is not necessary.

Thanks,
Jennifer
 

tag60

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For your first question--as long as it is documented in the note somewhere that it is the great toe, I see no problem with using that to be more specific in your diagnosis coding. I would not ask for that clarification in the assessment because it is already specified in the exam.

For your second question--here I would rely on the provider's documentation, not the nurse's intake statement. I've seen too many inconsistencies in this regard, and it's really up to the provider to document. Again, as long as I can find specific location documented somewhere in the note, I will use that.
 
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