Edd Physician Record Case Study

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Step 1: Review the ED physician record. Note presenting signs and symptoms, lab values, medical history, and the ED physician’s impression, as well as the reason why the patient is being admitted. Note any diagnostics or procedures performed in the ED. Don’t forget this part of the admission, because you might be using the ED record as the basis for an attending query, such as acute respiratory failure for a dyspneic patient intubated in the ED.

Step 2: Look for the physician’s document of the patient’s history and physical (H&P). Use the same review strategy you used for the ED record. Determine if the physician has a clear idea of the principal diagnosis. Identify if the physician is waiting for additional diagnostics or consults. Take note of any gaps in the documentation. Can each diagnosis be coded completely based on the documentation? How firm is each diagnosis—are there diagnoses that are noted as rule out, probable, possible, cannot confirm, etc.?
Make note of those diagnoses so that you can follow the progression of each diagnosis as the patient receives inpatient care. You don’t want a diagnosis to drop off without resolution. Ensure that there is enough clinical information in the chart at this point to support the diagnoses the physician chose. With an understanding of how principal diagnosis is determined, what do you
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Determine if the discharge summary follows, in logical progression, the flow you’ve seen in the chart thus far. Watch for diagnoses that come out of left field. Remember that the discharge summary carries the most weight when a chart is audited, so it’s really critical for the case to be wrapped up nicely at the end. Unfortunately, we often see is physician documentation of the condition of the patient at the time of discharge without consideration for the progression over time, or a very hurried, short summary. Sometimes diagnoses never mentioned during the stay show up in the discharge

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