Clean up code in the Professional Medical History

Aug 6th, 2022
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How to clean up code in the Professional Medical History

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hi guys welcome back to code master coach your medical coding tutor in todays video were going to be talking about what do we code from where do we get our information to assign our codes from the answer is the medical record the medical record contains the documentation for the reason that the patient came to the hospital in the first place it contains tests performed their findings therapies provided surgical procedures daily record of the patients progress and whatever else the physician documents now remember this medical record can be either electronic or in paper form more more today were beginning to see more electronic records now an inpatient medical record contains whats called a discharge summary or a final progress note this discharge summary is a in the form of a summation of the patients stay it includes the reason for the admission docHub diagnostic findings any treatment given a follow-up plan and the final diagnostic statement now a stay less than 48 hours r

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You cannot get a diagnosis removed. Usually it is people with psych diagnoses who make this request. You can request an Addition or Amendment. Each hospital has a form to fill out to do this.
The following is a list of items you should not include in the medical entry: Financial or health insurance information, Subjective opinions, Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
In medical professional liability litigation, evidence that a physician has intentionally altered or deleted information in a patients record, without including the requisite annotations, can have direct and severe ramifications.
DOCUMENTED CONDITIONS: All documented conditions, which coexist at the time of the encounter/visit and require, or affect, patient care treatment or management, should be coded. Conditions that were previously treated and no longer exist, are not coded.
A diagnosis listed in PMH must be supported as either a life-long permanent condition, or have additional supporting documentation elements within the same date of service (since each date of service stands on its own), such as medication which is documented for the diagnosis or used only to treat the diagnosis in
In your Results In Basket folder, right-click the message about the result you want to remove from MyChart.
You can ask, but they wont destroy or hide your medical records. The reason being those records are not the property of the doctor or the patient; they are of the hospital and it is simply illegal to destroy them.
Patients should also be allowed to ask questions and make consultations that can remain off the record at their request (as long as there is no risk to other people).

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