2. Review the AHIMA Resource:

AHIMA ICD-10-CM PCS Documentation Tips.pdf

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3. Review the following progress notes to identify if the medical documentation is complete. Indicate if the documentation is complete or incomplete. If incomplete, identify what needs to be clarified by the provider.

4. Only 1 member from each group needs to submit the assignment.

5. Submit the assignment on a Word document. Include the names of all participating group members.

For each of the following 5 progress notes, indicate if the medical documentation is complete. If the documentation is not complete, indicate what the provider needs to complete for an accurate code to be selected. See the example for what is expected.

1. Patient presents with symptoms of diabetes. A diagnosis of diabetes mellitus is made. Patient discharged with appropriate medications.
2. Patient presents to the physician office with a retained foreign body of glass in the right hand. The foreign body was easily removed with a lancet and tweezers. Patient discharged. No further treatment is necessary.
3. Patient has been hospitalized in a coma. Upon rounds, coma is confirmed. No new treatments were ordered. Will round again tomorrow.
4. Patient presents with myocardial infarction as indicated by EKG.
5. Patient presents with complaints of not being able to hear the television like she used to. Diagnosed with bilateral hearing loss, mixed type, no associated diagnoses or conditions. The extent of the hearing loss is mild.

Example:

The patient presents with constant feelings of lethargy. The patient is pale and appears weak. A diagnosis of anemia is made.

Medical documentation complete? ______yes __X____no

If no, what documentation does the provider need to complete for an accurate code to be selected?

1. What is the type of anemia?
2. Is the documentation due to nutrition or mineral deficits?
3. Is the anemia due to a neoplasm?
4. Is the anemia related to or due to chemo or radiotherapy treatments?
5. Document any cause-and-effect relationship between the intervention and the blood or immune disorder.
6. Document the specific drug if anemia is drug-induced.
7. Are there any lab findings?
8. Are there any associated diagnoses or conditions?