Table 1 List of documentation sources coders reported using
Types of Documentation | |
|---|---|
• Discharge summaries or ambulatory care records • Triage sheets • Transfer summaries • Service transfers • Progress notes (physician or nurses) • Nursing assessments • Operative reports or peri-operative reports • Referral letters • Consultations • Doctor orders | • Pathology reports • Laboratory test results • Microbiology reports • Diagnostic imaging reports • X-Ray reports • Radiology reports • Haemodialysis records • Transfusion records • Special procedures • Prescription orders • Patient histories • Patient physicals • Admission histories |