We often will see the physician document the patient’s condition with just the words “STABLE” or “AS ABOVE” on a chart note. These words alone do not qualifty as a narrative documentation on that date of service about the condition. This is from the SCAN HCC UniversityAsk a Coder : I continuously have a doctor that puts ‘same’ in the diagnosis field of the EMR or he will put “same as x-ray findings” Is this allowable? If not, PLEASE help me to explain to him that it’s not. A. There is no diagnosis code for “same”—I think that’s the best information you can give the physician. Diagnosis coding (or procedural coding for that matter) is always based upon the narrative documentation on this date of service. The physician must provide a narrative diagnosis on this date of service, in order for coding to be done. The physician is placing you and your organization at risk in the event of an audit. I suggest that you enlist the assistance of your manager or better ...