Is "not presenting with symptoms of..." defensible charting procedure?

[sonofva]

For example, can you write "not presenting with symptoms of PE" in your MDM to justify not ordering a dimer? Is this defensible if they come back and actually did have a PE? I'm sure there are other examples, but you get the idea?

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[southerndoc]

For example, can you write "not presenting with symptoms of PE" in your MDM to justify not ordering a dimer? Is this defensible if they come back and actually did have a PE? I'm sure there are other examples, but you get the idea?

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In general, if you miss anything you're possible to get sued. However, if you document they didn't have symptoms suggestive or consistent with a particular illness, it shows that you at least considered it. Considering it and it not fitting typical presentation is more defensible than not documenting it, which implies you didn't consider it. Not considering it can lay the grounds for a plaintiff to argue you're incompetent or didn't fully assess the patient/work the patient up. Improper or insufficient workups have potential for more successful litigation and higher payments than considering it and it not fitting a classic picture.