I have a specific provider who at times doesn't like to use a SOAP template or put a final diagnosis, I can make assumption as to why the patient is there or I can capture signs and symptoms, but for prenatal care, is it okay to make assumption here and capture O code for encounter of pregnancy supervision? or is it best practice to have the provider document final diagnosis?
Patient is 42 yrs old, 38 weeks. G2, P0
Patient is 42 yrs old, 38 weeks. G2, P0