A comprehensive guide to chart review elements for discharge and concurrent account coding
Patient Demographics & Timeline
Patient Information
Verify gender (Male, Female, Newborn) and age category (Adult, Child, Newborn) for accurate coding classification
Critical Dates
Document ED date, Observation date, Admission date, and Discharge date to establish complete patient timeline
Coding Type
Identify whether performing concurrent coding during stay or discharge coding for all accounts
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Admission & Emergency Documentation
Admission Order Review
Begin with the Admission Order folder, which contains the initial documentation authorizing the patient's hospital stay and treatment plan.
- Verify admission orders are complete
- Check physician signatures
- Confirm date and time stamps
ED Documentation
Review emergency department records for symptoms, conditions, and procedures performed such as:
- Laceration repair
- Intubation procedures
- PICC line placement
- TPA administration
- BIPAP treatment
- MDM (Medical Decision Making) notes
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History & Physical Examination
HPI - History of Present Illness
Document the patient's current condition and symptoms leading to admission
PMH - Past Medical History
Review previous medical conditions and chronic diseases
ROS - Review of Systems
Systematic review of body systems for symptoms
PSH - Past Surgical History
Document previous surgical procedures and outcomes
Social & Family History
Review SH (Social History) and family medical background
Physical Examination
Complete GE (General Examination) and PE (Physical Examination) findings
Additionally, review home medications, allergies, vital signs, and assessment plan for comprehensive patient evaluation.
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Clinical Notes & Progress Documentation
Consultation Notes
Review specialist consultation documentation including assessment plans and any bedside procedures performed during consultation
Progress Notes
Daily progress notes documenting patient status, assessment plans, and bedside procedures throughout hospital stay
Scanned Notes
Review any written documentation that has been scanned into the electronic medical record system
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Surgical & Procedural Reports
Operative Reports
When present, operative reports provide detailed documentation of surgical procedures performed during the hospital stay. These reports are critical for accurate procedural coding.
Anesthesia Reports
Review anesthesia documentation for type of anesthesia administered, duration, and any complications during surgical procedures.
Key Elements
- Pre-operative diagnosis
- Post-operative diagnosis
- Procedure performed
- Surgeon details
- Anesthesia type
- Complications
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Laboratory & Diagnostic Reports
Lab Reports
Review COVID test reports and other laboratory results essential for diagnosis confirmation
Radiology Reports
Review imaging studies including X-ray, CT, MRI, ultrasound, catheterization, lumbar puncture, and thrombectomy procedures
Pathology Reports
When present, pathology reports provide tissue analysis and biopsy results for accurate diagnosis coding
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Treatment & Medication Records
Medication Summary
Complete review of all medications administered during hospital stay, including dosages, frequencies, and routes of administration
Dialysis Records
Document dialysis treatments performed, including type, duration, and patient response to treatment
Transfusion Records
Review blood product transfusions, including type of product, volume, and any transfusion reactions
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Nursing & Case Management
Nurse Records
Nursing documentation provides continuous monitoring of patient status, vital signs, interventions, and response to treatment throughout the hospital stay.
Case Management
Review case management notes for discharge disposition planning, including post-acute care arrangements, home health services, and follow-up appointments.
- Discharge planning coordination
- Post-acute care needs
- Patient education documentation
- Follow-up arrangements
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Discharge Summary Review
Hospital Course
Complete narrative of patient's hospital stay, treatments provided, and clinical progression
Final Diagnosis
Principal and secondary diagnoses established at discharge for accurate coding
Discharge Plan
Post-discharge instructions, medications, and follow-up care requirements
How to Review Inpatient Medical Records