Abstracting Assignment Place in the Chart Where the Information Would be Found Information Found to be coded Chief Compl

[answerhappygod]

Abstracting Assignment
Place in the Chart Where the Information Would be Found
Information Found to be coded
Chief Complaint or reason for the encounter
Admitting Diagnosis
Should be #1 in the Discharge Summary problem List if the
documentation is adequate
Principal Diagnosis
Discharge Summary problem list
History of Present Illness
Past medical history
Past surgical history
Social History (DTA: drugs, tobacco, alcohol, high risk sex
behaviors, and unusual living conditions like homelessness)
Family history (same body system as the principal diagnosis)
Comorbidities (pre-existing conditions)
Only code these if they are applicable to THIS encounter:
Use the 4 M’s: Was it measured, monitored, medicated, or did it
make nursing care more labor intensive
Hospital Course (Day 1, Day 2, etc)
Complications (negative, unexpected events occurring during the
encounter/admission: look at any specifically that increased the
length of stay)
Hospital Course (Day 1, Day 2, etc)
Procedures (significant procedures: procedures which has a risk
of death and/or surgical risk and/or anesthesia risk and/or require
additional training for the physician)