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Wiki No Final Dx

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KoBee

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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

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Hi Kobee
Why not use dx OO9.523 and dx N88.2 closed cervix and dx Z34.8 since pregnant before?
I hope this helps you.
Lady T
 
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