Question for coders about errors about document integrity - pmk Posted: Jul 29th, 2015 - 5:30 pm
I was wondering how coders handle errors discovered as you are reviewing charts for coding. As a QA person, I occasionally need to verify patient information against a report I am checking. When checking previous reports in the permanent computer record, I often see pretty blatant errors, those dictated by doctors, missed by the transcriptionist or not blanked for uncertainty, medications, dosages, allergies, diagnoses, etc. I usually correct about 12-15 of these type of errors on a daily basis for the current (not permanent) reports I am checking. Since coders are held to a very high standard of ethics for patient care, how do you handle this? In my outside-the-hospital QA position, there really is no mechanism for addressing this, but I was wondering if there was for coders. I am a new coding student and just read the AHIMA Code of Ethics and wonder how this is approached in the "real world" of coding and how far your responsibility extends.
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