CS-adding new Dx or lab work-up in PN

[list]

While you writing your SOAP note, is that ok to add a new differential or lab workup in your list? Do you think it is ok becouse I didn't discussed with my patient? I did some changes to my list many times-specially in lab workup list I removed some and wrote a new one

Do I need to worry for this?

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[45408]

I did this quite regularly. I'm under the impression that you don't actually have to give your assessment and plan to the patient, you just have to give them closure to the encounter.

 

[DrTennis]

I'm sure you are fine. I think if I am not mistaken, FA or some other review source I read stated you should discuss more or less about 3 of the differentials or at least give a layman explanation of what you think may be going on with the patient. There were a couple of cases that I even went beyond 5 differentials or workups and had to actually add a number 6 or 7 line to my diff and workup list.