deyoung
Guru
Is it ok for a Dr to put "no change" on the progress note for the Dx or do they have to actual list the Dx? Thx! 
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Wiki "no change"
- Thread starter deyoung
- Start date
kbarron
Guest
no change
No change from what? What is the purpose of the visit? What is the chief complaint?. You would need more information to code this visit.
No change from what? What is the purpose of the visit? What is the chief complaint?. You would need more information to code this visit.
I agree. The diagnosis, rationale, or impression for the visit should be on the note. Correct me if I'm wrong but I believe that documenting the diagnosis or rationale is included in the documentation guidelines for E/M. Each progress note should stand on it's own. The diagnoses on the bill or claim form should be supported by what is in the progress note.
deyoung
Guru
Great, that's what I was thinking...the note should stand on it's own. The auditor shouldn't have to search the rest of the chart to figure out the Dx. 