Ask ECRI: Assigning a Diagnosis without Rationale
February 11, 2021 | Ambulatory Care Risk Management
A member recently asked for guidance to address patient concerns and to protect the provider and organization when a provider has made a diagnosis but has not documented a rationale.
In our response we focused on the importance of understanding the circumstances in which the diagnosis was made and the need to ensure that policies are in place related to proper documentation and addenda that might be needed. In addition, the health center should make sure the patient is properly informed and given the opportunity to discuss...