Here's the documentation guidelines on this:
"DG: For each encounter, an assessment, clinical impression, or diagnosis
should be documented. It may be explicitly stated or implied in
documented decisions regarding management plans and/or further
â€¢ For a presenting problem with an established diagnosis the record
should reflect whether the problem is: a) improved, well
controlled, resolving or resolved; or, b) inadequately controlled,
worsening, or failing to change as expected.
â€¢ For a presenting problem without an established diagnosis, the
assessment or clinical impression may be stated in the form of
differential diagnoses or as a "possible", "probable", or "rule out"
DG: The initiation of, or changes in, treatment should be documented.
Treatment includes a wide range of management options including patient
instructions, nursing instructions, therapies, and medications.
DG: If referrals are made, consultations requested or advice sought, the record
should indicate to whom or where the referral or consultation is made or
from whom the advice is requested."
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