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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
