Open the chart, "Control N" for new visit, template in CC "As a consequence of labs" which is now my catch phrase for any event that offers me documentation (IE the lab, x-ray, ER note or Screening Mammo with micro calcifications) Then HPI box for brief explanation, "Routine mammo is returne with a finding of microcalcifications", then code the problem, 793.81 Mammographic Microcalcifications.
Only takes a minute and you have a solid record of the reason for the new Dx,and your action and when you took it.
