Which documents in the medical record should be reviewed when coding?

The following documents in the medical record should be reviewed when coding:

1. Chief Complaint: This document provides a brief summary of the patient's reason for seeking medical attention. It should be reviewed to identify the principal diagnosis.

2. History of Present Illness (HPI): This document provides a detailed account of the patient's symptoms, including the onset, duration, severity, and location. It should be reviewed to identify additional diagnoses and to support the principal diagnosis.

3. Past Medical History (PMH): This document lists the patient's previous medical conditions and treatments. It should be reviewed to identify any co-morbidities that may affect the current diagnosis and treatment.

4. Social History (SH): This document provides information about the patient's lifestyle, including their occupation, hobbies, and social activities. It should be reviewed to identify any factors that may be contributing to the patient's current condition.

5. Physical Examination (PE): This document records the findings of the physical examination, including vital signs, general appearance, and specific findings for each body system. It should be reviewed to identify any abnormalities that may support the diagnosis.

6. Laboratory Tests: These documents provide the results of laboratory tests performed on the patient, such as blood tests, urine tests, and imaging studies. They should be reviewed to identify any abnormal findings that may support the diagnosis.

7. Imaging Studies: These documents provide the results of imaging studies performed on the patient, such as X-rays, CT scans, and MRIs. They should be reviewed to identify any abnormalities that may support the diagnosis.

8. Operative Reports: These documents provide a detailed account of any surgical procedures performed on the patient. They should be reviewed to identify any procedures that were performed and to support the diagnosis.

9. Consultation Reports: These documents provide the opinions of other healthcare professionals who have been consulted about the patient's care. They should be reviewed to identify any additional diagnoses and to support the treatment plan.

10. Discharge Summary: This document provides a summary of the patient's hospital stay, including the diagnosis, treatment, and prognosis. It should be reviewed to verify the accuracy of the information and to identify any additional diagnoses that may have been missed.

By reviewing all of these documents, coders can ensure that they have a complete understanding of the patient's medical history and condition, which will allow them to accurately assign the appropriate codes.