Transcription of Chapter 3: Sample - Lippincott Williams & Wilkins
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Chapter 3: Sample - Lippincott Williams & Wilkins
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.. Describe the basic steps taken to review a medical record for coding. The coding process begins with a careful and strategic review of the medical record (MR).
report itself, the anesthesia record, special consents for surgery, the recovery room record, and pathology reports for specimen analysis. Note the results of special procedures such as cardiac catheterizations, colonoscopies (lower endoscopies), esophagogastroduodenoscopies (upper endoscopies), and bronchoscopies, with or without biopsies.
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