Medical Record

Question 1

Can you code from other physicians

Answer 1

Yes as long as not conflicting even if not on dx summary

Question 2

Can you code location of infarct or strike from mri

Answer 2

Yes

Question 3

Organism of pna on culture not in record

Answer 3

Must query for confirmation

Question 4

Document ration my clinician ok to code

Answer 4

BMI
NIH stroke
Coma scale
Non pressure and pressure ulcer
Social determinants as long as clinician or provider accepts 

Associated dx must be documented

Question 5

Ippatoent path and radiology dx

Answer 5

Must be confirmed by attending

Except COVID