AHA Coding Clinic® for ICD-9 - 1984 September - October

Medical Records and the Medical Staff: A Joint Effort in Documentation

by Minnette Terlep, ART, director, Medical Records, St. Joseph Medical Center, Joliet, IL The Medicare prospective pricing system has placed greater importance on complete and accurate documentation in the medical record. In order to achieve such documentation, open communication must take place between physicians and the medical records staff. The first step is physician education. The medical staff needs to be made aware of the importance of ensuring that diagnoses are substantiated by the diagnostic findings documented in the medical record. The UHDDS definition of principal diagnosis (the condition established after study to be chiefly responsible for occasioning admission...

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