I work in Home Health, but knew you all would have much more experience with this one. My patient has multiple serious health problems--CHF, HTN, CAD, chronic renal insufficiency, Hep C and more. He's also bipolar and has been on meds for years.
My question is when doing the admission assessment, in my narrative I need to describe his movements which are clearly tardive dyskinesia--repeatedly sticking out his tongue pretty far, licking his lips, constantly.
Is calling the movements tardive dyskinesia a medical diagnosis and something I shouldn't do, or is it ok to call it that? If not ok, then do I just describe the patient's actions?
What do you do when charting and patient has this but you don't see the diagnosis anywhere on the physician's notes or assessments ?