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How does it compare to other sore throats you have had? (severity)
, Do you also have other symptoms? (associated signs and symptoms)
What are you doing when it hurts? (context)
How would you describe the pain? (quality)
What have you done to obtain relief? Did it work? (modifying factors)
Common Diagnosis coding process errors
Illegible physician handwriting
Illogical physician diagnosis documentation
Lack of physician documentation
Transcription errors by typist or voice-recognition systems
Content of the rest of the patient's medical record does not support the diagnosis documented
Lack of specificity
Hybrid Record
A combination of paper and electronic records; a health record that includes both paper and
electronic elements
Integrated health record
A system of health record organization in which all the paper forms are arranged in strict
chronological order and mixed with forms created by different departments
The Joint Commission
an independent organization that accredits healthcare organizations in the United States based
on performance standards
Longitudinal health record