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.
transcribed (typed). If applicable, go to the operative report to note operations/ procedures and the preoperative and postoperative diagnoses (Medical Report 3.4). Depending on whether it is a major operation or a minor procedure, it is best to recognize that MR forms related to operations or special procedures usually exist as a set of linked ...
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