Question: I am working on a chart with an impression documenting spondylosis causing spinal stenosis at L2-L3. Additionally, there is spondylolisthesis at L3-L4. The impression states radiculopathy. Should I include all four of these diagnoses?
Answer: Generally, you won’t be documenting symptoms when there are definitive findings in the impression. However, this rule only applies when the diagnoses in the [...]