Chap 5 ICD 10 content of Med Records Flashcards
The medical record is
the source document for coding.
Medical records contain a variety of reports. These include the following:
– Reason the patient came to the hospital
– Tests performed and their findings
– Therapies provided
– Descriptions of surgical procedures
– Daily records of patient progress
The discharge summary provides
a synopsis of the patient’s stay.
POA indicator
present on admission indicator; a data element that applies to diagnosis codes for claims involving inpatient care
Provider
a physician or any qualified health care practitioner (such as a nurse practitioner or physician assistant) who is legally accountable for establishing the patient’s diagnosis
The coder must make sure that the medical record documentation supports
the principal diagnosis.
If it appears that another diagnosis should be designated as the principal diagnosis, or if conditions not listed should be reported,
the coder should follow the health care facility’s procedures for obtaining a corrected diagnostic statement.
Review of the inpatient medical record should begin with the discharge summary, when available,
it provides a synopsis of the patient's hospital stay, including admission diagnosis, significant diagnostic findings, the treatment given, the patient's course in the hospital, the follow-up plan, and the final diagnostic statement.
