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A facsimile from Immunization Fax Cover sheet To: Medical Affairs Branch (Immunology Data/Medical Record Review) MAY Fax Number: 301-427-3433 Name: PHS#: Phone#: Email: Date: Do not call MAY to verify

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Instructions and Help about oon medical records cover

Hi guys welcome back to code master coach your medical coding tutor today#39’s video we're going to be talking about what do we code from where do beget 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 placate contains tests performed their findings therapies provided surgical procedures daily record of the patient'progress and whatever else the physician documents now remember this medical record can be either electronic or in paper form more today we'rebeginning to see more electronic record snow an inpatient medical record containswhat'’s called a discharge summary or final progress note this discharge summary is an in the form of a summation of the patients#39’s stay it includes the reason for the admission significant diagnostic findings any treatment given follow-up plan and the final diagnostic statement now a stay less than 48 hours requires a final progress note so summation of that patient stay willing to be in a form of a discharge summary or final progress note and remember that stay has to be 48 hours orless to justify a final progress note which is usually only a paragraph longhand not a lot to document but stay greater than 48 hours does require thorough discharge summary you also have what#39’s called a history and physical examination it#39’s completed the day of or within seven days of admission, and it contains the patient's chief complaint reason for the admission history of the complaint how long they've had it family and social history related to the complaint is it genetics something that other family members also have is it something because of their lifestyle a disease process or condition because of their lifestyle an examination of the patient includes to include the body systems review memory from head to tail usually and then plan of care, so you have the history and physical on admission and a discharge summary at the end of the state and in between there you have daily progressed notes each day that a patient is in hospital the physician should document daily progress notes that are brief statements of what#39’s going on with the patient and I always try to remind my students as long as the patient is in the hospital there should be a daily physician progress note long-term care once every 30 days#39’m subacute care once every three days but as long as that#39’re in a hospital setting there should be documentation or progress note every day that that patients in house additional documents that you'll see in patient medical record include x-ray reports which helped me as a coder because if the physician says the patient has fractured femur and that's all it gives me I can go to the x-ray important determine where was a fractured femur was it at the head of the femur or on the shaft of the femur or where another report is a path report a pathology report now remember a path...

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What is an image of a?

An image of a is a visual representation of the object 'a'.

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Individuals or organizations who possess the rights to 'a' are required to file an image of 'a'.

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You can fill out an image of 'a' by providing detailed information about the object and attaching the visual representation.

What is the purpose of an image of a?

The purpose of an image of 'a' is to provide a visual reference for the object and help in its identification.

What information must be reported on an image of a?

Information such as dimensions, colors, and features of the object must be reported on an image of 'a'.