This is one of the big problems I see with the move to EHR .... EVERYTHING (including the kitchen sink) gets included in the Dx list!
You use only the condition(s) being treated, or considered. What do I mean by "considered."
Let's say a patient sees the doctor for a common cold. This is a self-limiting problem. HOWEVER ... if the patient happens to have DM2 well controllled, and a history of chronic sinusitis ... these are conditions that the physician will need to consider in diagnosing and treating the cold.
Let's say a patient comes to the doctor for a sprained wrist. The past problem list includes GERD and allergy to sulfa drugs. These two conditions have nothing to do with the evaluation and treatment of the sprain.
When in doubt, you'll have to query the physician.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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