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Different Diagnosis between Closure and Patient Note!

1K views 1 reply 2 participants last post by  freebielady 
#1 ·
Hi all:

Just a short question. When we say closure to SP, is it ok if the Dx we tell them and the Dx we really write on the patient note are not exactly the same?

Thank you!
 
#2 ·
Yes

Yes it is the Pt Note and the SP notes are graded differently. they only grade you on how you close not if you give the right differentials. However remember that if you even need to preform a Rectal, Pelvic or Breast exam you tell them you will have to. If you forget to its ok you still write it on your Patient note to get points there but the SP does grade you on whether or nto you informed him that test had to be preformed!
 
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