The table of contents for the problem-oriented record is cal…
The table of contents for the problem-oriented record is called the __________, and it is filed at the beginning of the record and contains a numbered list of the patient’s problems, which helps to index documentation throughout the record.
Read DetailsA physician lists “viral pneumonia” as the final diagnosis….
A physician lists “viral pneumonia” as the final diagnosis. However, the coder notes that laboratory results state “gram-negative bacteria.” There is also documentation of chest pain, fever, and dyspnea due to pneumonia. What should the coder do?
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