Hello,

I am auditing documentation and having a problem with whether listing in the assessment, a diagnosis, with a code and then down in the plan following with a brief statement such as this example is considered acceptable:

A: Allergic Rhinitis (477.9)
Osteoporosis (733.00)
Hyperlipidemia (272.4)

P: Increase oral fluids
Continue usual med therapy
Perform labs as ordered

I feel there is not enough connection to the problem and what the treatment/management is going to be which leaves too much room for assumption. My difficulty is explaining to the provider so they understand that this is not accepted documentation. Can anyone assist with how they have managed to explain this and what guideline they were able to obtain as verification?

thanks