I think you will get the same answer on FB -- - Query and educate Posted: May 28th, 2016 - 10:22 pm In Reply to: As per usual, this is the kind of answer I expected to the - posters questions.....
If you ask this question on Facebook, you're going to get the same answer. When faced with documentation that is unclear or inadequate, we query and educate the provider.
You would also find that if you post some examples of MT errors, you're going to get the answer that those things don't affect us.
On an inpatient stay, I don't get the diagnoses from the list of discharge diagnoses and I don't get the operative procedures from the title on the report. Instead, I build those from the entire medical record. I read every item of documentation in the record-- dictated, typed by the doctor, handwritten and scanned, labs, x-rays, pathology reports, nursing notes, respiratory therapy notes, physical therapy notes, everything. By the time I get to the discharge summary, I know what is supposed to be on it. If what the doctor wrote does not match, I query if it is something that will make it impossible to code optimally or which will affect the DRG assignment on that case. I will also get anything corrected that might affect future patient care.
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