ICD-10-CM Introduction to Inpatient Diagnosis Coding IV: Lesson 8: Review of the Source DocumentAbstract This lesson provides an introduction to common medical record source documents and the process for reviewing these documents in order to select diagnosis codes for reporting in accordance with the most recent version of the ICD-10-CM Guidelines for Coding and Reporting.Before beginning this lesson, you should have access to the most recent version of ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification). If you do not have the most recent copy of an ICD-10-CM code book, then click the Resources tab to find and download the necessary documents. Be sure and download both the index and tabular listing of ICD-10-CM as well as the External Cause of Injuries Index, the Table of Drugs and Chemicals, and the Table of Neoplasms.To get the most from these lessons, it's a good idea to complete them in order.The codes and information in this lesson are updated as needed and receive a comprehensive review annually.Learning Objectives By the time you have finished this lesson, you should be able to do (or know) the following:oIdentify the inpatient medical record source documents used for coding.oIdentify valid documentation contained in each source document that can be used appropriately for coding.oDescribe the action to take when there is a conflict in patient documentation.oRecall the factors that prompt a coder to look for additional diagnoses.oIdentify the action to take when source documents are missing.Overview: Inpatient Medical Record Source Documents The medical record is a legal document used to support the patient's diagnosis, justify treatment, document the course of treatment and results, and provide a method of communication for continuity of care among providers. It is also used as a source document for coding and billing.1More Information about Inpatient Medical Record Source Documents Inpatient medical records are composed of documents arranged in a uniform, organized manner.These documents may be in paper format, electronic format, scanned, or some combination of these formats. Combinations of medical record formats are called hybrids.
Scanned documents may be handwritten forms or notes. The coder may face the challenge of reading the handwriting in a scanned document in which the reproduced writing is not clear or dark enough. The arrangement and sequence of documents varies depending on facility policy and procedure and documentation format. Documents are, in general, arranged in date order by type of document. When in electronic format, documents may be located using drop-down menus (tabs) that group and identify particular parts of a record. In essence, they are electronic file folders. The appearance of an electronic record depends on the vendor and any facility-specific customizations.
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Electronic health record, Physical examination, Medical diagnosis