maine4me
Guru
Patient is seen in the office for clearance for a dental procedure. The patient has mild mental retardation which requires sedation for dental work. Anyway, the doctor previously treated the patient for pneumonia. During the current encounter the doctor notes in the plan "PNA - completed abx course, still with cough but normal pt behavior, no fever/chills. Added Mucinex."
My question is would I use the pneumonia diagnosis or the cough?
My question is would I use the pneumonia diagnosis or the cough?