Chapter 3
Medical Records: The
Basis for All Coding
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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
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Ten Steps for Coding
From Medical Records
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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).
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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.
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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.
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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)
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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
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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
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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
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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.
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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
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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
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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!
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