Comprehensive Guide to Inpatient Medical Record Review: CHART Review Protocol for Coders

Comprehensive Guide to Inpatient Medical Record Review: CHART Review Protocol for Coders
Welcome to this comprehensive guide on conducting thorough CHART reviews for inpatient medical records. This presentation will equip medical coders and auditors with a systematic approach to reviewing both discharged accounts and concurrent coding cases, ensuring accuracy, compliance, and optimal reimbursement.
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Understanding the Patient Demographics and Timeline
Patient Demographics
Begin by confirming basic patient information:
Gender identification (Male/Female/Other)
Age category (Newborn/Child/Adult/Geriatric)
BMI calculation (relevant for obesity-related coding)
Special patient populations (pregnant, immunocompromised)
Demographics impact MS-DRG assignment, coverage policies, and quality measures reporting.
Encounter Timeline
Document and validate all relevant dates:
Emergency Department presentation date and time
Observation status periods (with exact hours)
Formal admission date and time
Discharge date and time
Length of stay calculation (crucial for per diem payment structures)
Timeline accuracy impacts MS-DRG validation, utilization review, and appropriate level of care determinations.

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Concurrent vs. Discharge Coding Approaches
Concurrent Coding Methodology
Concurrent coding involves reviewing and assigning codes while the patient is still admitted, requiring:
Real-time documentation analysis
Provisional principal diagnosis determination
CDI queries during the admission period
Daily progress note review
Continuous reassessment as new clinical information emerges
Benefits include earlier reimbursement, proactive query opportunities, and reduced DNFB (Discharged Not Final Billed) statistics.
Discharge-All Coding Methodology
Discharge-All coding occurs after the patient has been discharged, requiring:
Complete record review including discharge summary
Final principal diagnosis determination
Retrospective CDI queries if documentation gaps exist
Comprehensive POA (Present on Admission) indicator assignment
Final procedural service capture
Benefits include comprehensive diagnosis capture, more definitive coding, and complete documentation availability.
1
Admission
Initial coding based on admission diagnosis and presenting symptoms
2
Treatment Period
Concurrent reviews capture evolving clinical picture
3
Pre-Discharge
Update codes based on confirmed diagnoses and treatments
4
Discharge
Final review incorporating discharge summary findings
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Admission Documentation Analysis
Proper review of admission documentation forms the foundation for accurate coding and establishes medical necessity for inpatient status.
1
Admission Order Verification
Confirm the presence and validity of physician orders specifically authorizing inpatient admission, including:
Order date and time (must precede inpatient services)
Ordering provider credentials (authorized to admit patients)
Documented medical necessity for inpatient level of care
Two-midnight rule compliance documentation
Status change orders (if transitioning from observation)
2
Admission Source Documentation
Identify and document the patient's point of origin:
Direct admission from physician office/clinic
Transfer from another facility (acute/non-acute)
Admission from ED (review ED documentation)
Post-surgery admission from ambulatory surgery
Admission following observation services
3
Initial Order Set Review
Examine admission order sets for:
Initial diagnostic studies ordered
Medication reconciliation documentation
Therapy services initiation (PT/OT/Speech)
Dietary consultations and restrictions
Initial treatment plan documentation


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Emergency Department Documentation Review
Critical ED Elements for Coding
Emergency Department documentation often contains the initial manifestations of conditions that become inpatient diagnoses. Review thoroughly for:
Chief complaint and presenting symptoms (establishes POA status)
Triage assessment and initial vital signs
Progression of symptoms during ED stay
Severity indicators for acute conditions
Medical decision-making (MDM) documentation reflecting complexity of care
ED documentation establishes the baseline clinical status and is essential for determining whether conditions were present on admission (POA) or hospital-acquired.
ED Procedures Requiring Coding
Many significant procedures are performed in the ED and must be captured for complete coding:
Laceration repairs (simple, intermediate, complex)
Intubation and ventilatory support initiation
PICC line and central line placements
TPA (tissue plasminogen activator) administration
BiPAP/CPAP initiation
Fracture care and reductions
Lumbar punctures and other diagnostic procedures
Cardioversion or defibrillation
1
Initial Assessment
Review triage notes, chief complaint, and initial vital signs
2
Diagnostic Studies
Identify point-of-care testing, imaging, and other diagnostics
3
Interventions
Document all treatments and procedures performed in ED
4
Disposition
Note decision for admission, including clinical reasoning
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History and Physical Examination Analysis
The History and Physical (H&P) document serves as the foundation for establishing diagnoses and treatment plans. A comprehensive review includes all these critical components:
History Components
HPI (History of Present Illness): Detailed chronology and characteristics of current complaints
PMH (Past Medical History): Pre-existing conditions that may affect current care
PSH (Past Surgical History): Previous procedures relevant to current treatment
SH (Social History): Smoking, alcohol, occupation, living arrangements
FH (Family History): Hereditary conditions that may influence diagnosis
ROS (Review of Systems): Systematic review of body systems for additional symptoms
Physical Examination
General appearance and vital signs (temp, BP, pulse, respirations, O2 sat)
System-specific examinations (cardiovascular, respiratory, etc.)
Neurological status assessment (GCS, mental status)
Wound characteristics and descriptions
Functional status assessment
Pain evaluation (location, severity, character)
Clinical Assessment
Assessment: Working diagnoses with clinical reasoning
Plan: Detailed treatment approach for each diagnosis
Home medications: Reconciliation and continuation decisions
Allergies: Documented reactions and severity
Clinical risk factors identified
Initial severity of illness indicators
Look for specificity in documentation, such as chronic vs. acute conditions, laterality, anatomical details, and etiology statements that support code assignment. Pay particular attention to the Assessment and Plan section, as this often provides the most definitive diagnostic statements.
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Consultation and Progress Notes Evaluation
Specialist Consultation Review
Specialist consultations often provide the most specific diagnostic information and detailed treatment plans for complex conditions:
Verify that each consultation was requested by the attending physician
Review reason for consultation and clinical questions posed
Identify specialist-specific diagnoses that may not appear elsewhere
Document bedside procedures performed by specialists
Note specialist-recommended medications and treatments
Track follow-up recommendations for ongoing care
Consultation notes from specialties like cardiology, neurology, and infectious disease often contain the most definitive diagnostic statements and may clarify conditions that were initially uncertain.
Daily Progress Notes Examination
Progress notes document the patient's clinical course and are essential for identifying complications and evolving diagnoses:
Review daily assessment updates for new or changed diagnoses
Track clinical indicators showing improvement or deterioration
Identify bedside procedures documented only in progress notes
Note medication changes and reasons for modifications
Check for documentation of complications or adverse events
Review resident notes with attending attestations
Progress notes often contain the first documentation of hospital-acquired conditions like pressure ulcers, infections, or adverse medication reactions that may not be highlighted in the discharge summary.
1
Initial Assessment
Working diagnoses based on presentation
2
Diagnostic Refinement
Evolving clinical picture with test results
3
Treatment Response
Documentation of clinical improvement or complications
4
Resolution Planning
Preparation for discharge with final diagnoses
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Procedural Documentation and Laboratory Analysis
Operative Reports
Thoroughly review all operative reports for:
Pre-operative diagnosis vs. post-operative diagnosis discrepancies
Detailed procedure description for accurate PCS coding
Approach (open, percutaneous, endoscopic)
Devices placed or used (type, material, if left in place)
Intraoperative findings that may establish new diagnoses
Complications encountered and how they were addressed
Multiple procedures performed during same operative session
Laboratory Reports
Review all laboratory studies including:
COVID-19 and other infectious disease testing results
Blood cultures and sensitivity reports for specific organisms
Critical lab values and their clinical significance
Trending lab values showing improvement or deterioration
Specialized studies like cardiac enzymes, D-dimer, procalcitonin
Laboratory evidence supporting clinical diagnoses
Drug levels for therapeutic monitoring
Radiology Reports
Examine all imaging studies for:
X-ray, CT, MRI, and ultrasound findings and impressions
Interventional radiology procedures performed
Cardiac catheterization findings (stenosis percentages)
Contrast usage and any related adverse effects
Comparison with prior studies showing progression/resolution
Incidental findings that may require additional coding
Radiologist recommendations for follow-up studies
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Special Documentation and Ancillary Services Review
Critical Ancillary Documentation
These specialized records often contain unique information not duplicated elsewhere in the chart:
1
Pathology Reports
Review for definitive diagnoses of neoplasms (benign vs. malignant), infection confirmations, and tissue-specific findings that support higher specificity coding.
2
Anesthesia Records
Examine for monitored anesthesia care details, difficult intubations, physiological monitoring during procedures, and any anesthesia-related complications.
3
Dialysis Documentation
Review for frequency, duration, complications during treatment, access site issues, and modifications to standard protocols.
4
Transfusion Records
Document blood product types, quantities, reasons for transfusion, and any transfusion reactions or complications.
Nursing and Case Management Documentation
These documents often contain key clinical details and important discharge information:
Nursing Notes: Often first to document changes in patient condition, wound characteristics, skin breakdown, intake/output measurements, and patient education
Medication Administration Records: Document actual medications given, not just ordered, including PRN medications with reasons for administration
Scanned Written Documentation: May include procedural consent forms, patient-reported histories, or outside facility records
Case Management Notes: Critical for discharge disposition codes, social determinants of health, and post-discharge service arrangements
Therapy Notes: Physical, occupational, and speech therapy assessments often document functional status and cognitive impairments
These documents provide essential context that supports medical necessity for services rendered and helps establish severity of illness.
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Discharge Summary and Final CHART Review Checklist
Discharge Summary Analysis
The discharge summary serves as the definitive document for final diagnoses and should be thoroughly reviewed for:
Principal diagnosis statement (condition established after study responsible for admission)
Secondary diagnoses with clinical indicators supporting their inclusion
Hospital course detailing treatments, responses, and complications
Procedures performed with dates and relevant findings
Reconciliation of admission diagnoses with discharge diagnoses
Discharge disposition (home, SNF, rehabilitation, etc.)
Discharge medications and follow-up instructions
Compare the discharge summary with documentation throughout the stay to identify any discrepancies requiring physician query.
Final CHART Review Checklist
Demographics
Verify all patient details are accurate and consistent
Timeline
Confirm all dates align with services provided
Diagnoses
Ensure all documented conditions are coded
Procedures
Capture all interventions with correct approaches
POA Indicators
Verify present-on-admission status for all diagnoses
Remember to evaluate the clinical validity of all codes assigned, ensuring the documentation supports medical necessity for the inpatient stay. When discrepancies exist between different parts of the record, the discharge summary generally takes precedence, but physician queries may be necessary to resolve conflicting information. Complete your final review by checking for any missing POA indicators, unspecified codes that could be more specific, or missing procedures documented throughout the stay.
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