Chapter 3 Medical Records The Basis for All

Format of Medical Records • The medical record (MR) format can be different from one institution to another, but the contents and data remain consistent • Different MR formats include: – Problem-oriented MR (POMR) • Allows physician to focus on all problems • Four main parts – 1) Database, 2) problem list, 3) initial plans; and, 4) progress notes – Source-oriented MR • Organized by departments or units (e. g. - Radiology, Laboratory) – Integrated MR • Strict chronologic order Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Ten Steps for Coding From Medical Records Copyright © 2012 Wolters Kluwer Health |

Step 1 • Review Face Sheet or Registration Record – The Face Sheet (FS) or Registration Record is the front page of the medical record – It contains basic patient identification (demographic) data, insurance information, and sometimes clinical data, such as the admitting and final diagnoses. Certain information that can be derived from the FS can help narrow coding choices and should not be overlooked (e. g. , male or female, age of patient, religion). Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 2 • Review History and Physical, Emergency Department Report, and/or Consultant’s Report – These forms are formatted very similarly but contain a patient assessment by the attending, emergency, and consulting physicians • As described by the patient (subjective data), the history is a very important form that uncovers the chief complaint, history of the present illness, a review of body systems, and the patient’s personal, family, and social history. • As observed by the physician (objective data), the physical examination includes a system-by-system physical examination by the provider to collect information on the patient’s condition. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 2 (continued) • Review History and Physical, Emergency Department Report, and/or Consultant’s Report – If a patient is admitted through the emergency room, review the presentation of the patient and initial treatment/orders given. Emergency room diagnoses should be considered in the context of admitting impressions and assessments – Review the attending physician’s H&P to determine the reason for admission and provisional diagnoses – A Consultant’s Report contains an expert opinion requested by the attending physician to aid in the diagnosis and treatment of the patient – The H&P is especially important because it reveals the initial reason(s) the patient came to the hospital and was admitted. This, in turn, helps the coder to begin the process of determining the possibilities for principal diagnosis selection. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 3 • Review Operative Reports, Special Procedure Reports, and/or Pathology Reports – The Operative Report is usually dictated by the surgeon/physician and then transcribed (typed) by a transcriptionist – Use the operative report to note surgeries/procedures and preoperative and postoperative diagnoses – Review pathology reports to note any abnormal findings in body tissues (specimens) Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 4 • Review Physician’s Progress Notes – Progress notes include an admit note; notes that relate to the patient’s condition, progress, complications, and response to treatment; and a discharge note – Review physician’s progress notes for significant diagnoses, new findings or conditions, and resolution of problems or complications Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 5 • Review Laboratory, Radiology, and/or Special Test Reports – Laboratory work includes several types of chemistry tests, analyses, cultures, and other examinations of body fluids or substances such as blood, urine, stool, and pus – Radiology reports include radiographs, computed tomographic scans, magnetic resonance images, arteriograms, and so on – Review laboratory, x-ray, and special tests to note any abnormal results and clarify treatments given through physician documentation Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 6 • Review Physician’s Orders – Physician’s orders are written or verbal orders to nursing or ancillary personnel directing all treatments and medications to be given to the patient – Review the physician’s orders to determine the treatments given Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 7 • Review the Medication Administration Record (MAR) – The MAR provides documentation of the drugs given to the patient, including the names of drugs, their dosages, the times given, and their routes of administration (Note drugs given and link them to possible diagnoses that may be found through a more in depth review of the medical record) (e. g. - IV antibiotics given and further review of the record uncovers UTI documented in patient’s progress notes). – The nurse or physician administering the drug signs off on all entries. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 8 • Review Discharge Summary (DS) or Clinical Résumé – The DS is usually dictated by the attending physician and then transcribed (typed) • Summarizes the patient’s course in the hospital, the patient’s condition on discharge, discharge instructions, and plan for follow-up care • Includes all final diagnoses, as well as any significant principal procedure and any other procedures Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 9 • Assign Codes – The Coder/Abstract Summary Form is a form typically used by coders to summarize their MR review and assign and sequence the patient’s codes – Assign codes by following UHDDS rules, coding conventions, and guidelines covered in Chapter 2 Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Step 10 • If needed, submit Physician/Coder Query/Clarification Form – The Physician/Coder Query/Clarification Form is typically used as a good-faith communication tool between coders and physicians to clarify proper code assignment or whether or not a condition was present-on-admission (POA) for a patient care episode – If in doubt, query the physician, and remember, “if not documented, not done. ” Without sufficient documentation, you cannot code, because documentation is the basis of all coding! Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins