Question

John has been seen by Dr. Victor. As you look at the medical record in preparation for coding the diagnosis for today, you see that Dr. Victor has not provided a diagnostic code that would uphold the need for the procedures to the insurance company. From past diagnoses, you see that there have been diagnoses that could be used. What would you do and why?

Answer 1

It is imperative for the doctor to properly document the management of a patient, including his all signs and symptoms, previous history, and current diagnosis. Because it will provide immense help for hospital authorities and patients, if the patient has any claims, they should give all present treatment, including investigations, medication, and diagnosis. They need to understand if the patient has this condition before starting the policy. If anyone includes past diagnosis instead of the present, they may not get aid from insurance companies.

A consultant's certificate with diagnosis, including the date when symptoms first occurred, is necessary for patients' documents. Because it should be submitted to the insurance policy to get assistance from them, the nurse should inform the doctor to write down the diagnosis to get insurance for patients instead of writing the previous diagnosis.