Job Description
Job Description: responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation. confer with the appropriate caregiver on the additional documentation that may be required. achieve a complete medical record by the time of patient discharge in order to ensure quality documentation that reflect the patients’ diagnose
8:00 AM
Coders start the day by pulling their assigned chart queue. In a hospital setting, an inpatient coder might work 15–25 charts per…
8:30 AM
Open the first chart. Read the operative report, discharge summary, and physician notes. Assign the principal diagnosis code (the…
10:30 AM
Encounter a complex chart — a patient with multiple comorbidities and a surgical complication. You spend extra time to capture eve…
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