Having a debate, as a coder if no final diagnosis is documented, it is okay for us to capture signs and symptoms. We have a provider who feels there is no need to document a final diagnosis and want us to assume the diagnosis. If anyone was looking at this chart note, would you just make an assumption of pregnancy diagnosis?
Here is an example of chart note:
currently 23-year-old was seen a week ago which IUD and a positive pregnancy test She wanted the IUD removd -she was told of the risks of an ectopic and was counseled -a repeat HCG shows normal increase -she has no pain or bleeding -vagu/s today shows a normal iup crl 0,5 cm 6wks 2days -at patient request she was referred for a termination to Family Planning Associates medical grp inc in Riverside see TVS photo
Here is an example of chart note:
currently 23-year-old was seen a week ago which IUD and a positive pregnancy test She wanted the IUD removd -she was told of the risks of an ectopic and was counseled -a repeat HCG shows normal increase -she has no pain or bleeding -vagu/s today shows a normal iup crl 0,5 cm 6wks 2days -at patient request she was referred for a termination to Family Planning Associates medical grp inc in Riverside see TVS photo