Coding Documentation
What documentation must provide
The record must be legible, authenticated, complete, and timely, and it must establish the link between a condition and the encounter. Inpatient records typically include the H&P, progress notes, consultations, operative report, pathology, and discharge summary; outpatient records center on the chief complaint, history, exam, and medical decision making.
The cardinal rules
Code only what the provider documents. Laboratory values, medications, and nursing notes may trigger a question, but they do not by themselves authorize a diagnosis code. A problem list entry that no provider evaluated during the stay generally is not codable. Documentation that is ambiguous, conflicting, or internally inconsistent is a query opportunity, not a guessing opportunity.
Integrity risks
Cloned or copy-pasted text, templated exams that do not match the patient, and late entries that are not properly amended all weaken the record's credibility. Amendments must not alter the original entry, and the author must be identifiable. Verbal orders and telephone orders must be documented and countersigned per policy.
Common question traps
Watch for "history of" versus an active, treated condition; findings documented only by a consultant when the attending did not address them; and signs or symptoms coded when a definitive diagnosis is documented (code the diagnosis, not the symptom).
Worked rule of thumb
In the outpatient setting, diagnoses documented as probable, suspected, rule out, or working diagnosis are not coded - code the signs and symptoms instead. In the inpatient setting, those same terms are coded as though the condition were confirmed. The reverse error - quietly coding a rule-out diagnosis on a claim - is both a coding error and a compliance exposure.