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Wiki Tenderness vs Pain

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kyannekis

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I often see in exam abdominal tenderness but then have a final dx of abdominal pain. Should I provide education to providers that it's better to use the tenderness instead of pain as the final diagnosis? Any feedback is greatly appreciated.
 
Ultimately it is up to the provider to make the medical determination between pain and tenderness. I would possibly ensure that the provider is aware of that there are two different codes tenderness vs pain as they may be coding pain unaware that this is a specific code for tenderness.

Beyond that this would be a medical decision and outside of our scope of practice.
 
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