After discharge of a patient, I review the physician’s documentation, lab and radiology content and the entire patient medical record.
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Get it written →Consider the following scenario and identify the HIM professional position described: After discharge of a patient, I review the physician’s documentation, lab and radiology content and the entire patient medical record. If I identify an incomplete diagnosis and treatment in physician documentation, I send a query to the physician to seek clarity in the patient record before coding and billing are completed.
Clinical Documentation Improvement
Data Analysis and Reporting
Scanning and Record Completion
Medical Coding of diagnosis and treatment
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