nurseshots

when an additional visit is made we document at the top of the note scheduled visit? no explain___(example: av to assess patient cardiac status). then under primary or pertient diagnosis: we put only the primary dx like dm ii. my question is when you make an av, it is for a specific reason. not a "routine visit", so ur in the home assess patient, possible call md-report b/p status...etc. or even short visit because pt is sent to er..whatever.... is it true? neccessary? required? or what ? that you not only document assessment, actions, blah blah on cardiovascular...da da..but also document teaching/education on dm ii or whatever the primary dx happens to be? or visit is: not a billable visit, won't get paid for the visit if teaching of primary not on note, every note must contain teaching on primary dx no matter what? help!