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Chapter 3: Sample

09/12/2008 10:37 Page 41 Aptara Inc. Chapter 3. medical Records: The Basis for All Coding Chapter Outline . Identify administrative and clinical data contained in medical records that are important to the coding format of medical Records process. Content of medical Records . Explain problems associated with coding from Incomplete medical Records incomplete medical records. Ten Steps for Coding From medical Records . Identify various medical reports important to the Testing Your Comprehension coding process. Coding Practice I: Chapter Review Exercises . Demonstrate coding from medical reports by using Coding Practice II: medical record Case Study the 10-step method.. Demonstrate the use of a Coder/Abstract Summary Chapter Objectives Form and a Physician/Coder Query/Clarification Form.. Identify common formats of the medical record .

Chapter Outline Format of Medical Records Content of Medical Records ... CHAPTER 3 Medical Records: The Basis for All ... and plan for care. The Emergency Room or Emergency Department Report provides initial diagnosis and treatment information by the emergency room physician. If a patient is admitted through the emergency room, review the

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