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2 pages/β‰ˆ550 words
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Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Coursework
Language:
English (U.S.)
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Topic:

Health Record Analysis Memo (Health, Medicine, Nursing Coursework)

Coursework Instructions:

Assessment Directions:
Imagine you are the coding supervisor at University Medical Center. One of your coders from the Same Day Surgery Center brings a chart to your attention. The coder feels the health record has poor documentation and should be reviewed by the Clinical Documentation Improvement Team.
You need to review the patient record (attached) to determine if you agree with the coder and write a memo to the Clinical Documentation Improvement Manager notifying her of your findings.
Follow the steps below to complete this assignment:
1. Review the patient chart, which is attached
2. After thoroughly reviewing the chart, determine if you agree with the coder. Does this chart have poor documentation? Why or why not?
3. Assign all appropriate ICD, CPT, and/or HCPCS II codes to the patient record. You may choose to use the code books or any encoder to do this.
4. Write a memo to the Clinical Documentation Improvement Manager to explain your findings. This memo should address the following:
a. Summarize your findings
b. Explain how your findings impact the code assignments
c. Support your findings and explanations with examples from the patient record.
d. Recommend the course of action that the CDI Manager should take to ensure quality documentation for this patient record.

Coursework Sample Content Preview:
Health Record Analysis Memo
Student’s Name
Institution
Tutor’s Name
Date of Submission
Health Record Analysis
When writing code or recording a chart, there is a need to find balance among the simplicity and complexity by continually evaluating the different tradeoffs that are available (Kampf, 2016, p.1). Therefore, a well-coded chart strikes a balance through elegance, clarity, efficiency, design, layering, readability, and simplicity. The chart has poor documentation. The chart lacks clarity on essential parts of the documentation. For instance, when the coder inputs documentation about the head, ears, nose, and throat, the coder documents ‘Negative’, which would be interpreted in a real sense that the patient does not have the mentioned parts of the body. The documentation lacks a proper design. The chart’s information is not systematically arranged to group the same type of patient data in one section. For instance, after noting that the nose is ‘Negative’ in the upper section of the documentation, the coder notes again on the lower section that the nose is ‘Normal for the entire exam.’ This coding gives confusing information.
Additionally, the chart lacks good readability. Readability ensures proper comments are written, conventions are followed, and variables are named wisely (Kampf, 2016, p.1). The arrangement of the patient information captured in the chart does not give easy readability unless the coder is consulted. Also, the presentation of the data is not as appealing to a reader. Above all, the chart lacks simplicity in its presentation of the information coded in it. Very much information is captured and documented randomly and therefore gives the chart a detailed look, ma...
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