I work in an Inpatient Psychiatric Facility. Is it standard practice to have a discharge summary in a chart to code from? I also go through the chart to pull out any diagnosis that the doctor documented and signed. I was told today to code from a checklist form that the doctor created, however his signature is not on this form. If the doctor signed this form I can code from it, correct? I just don't want to do anything that will put my certification or anything else in jeopardy. I have always been told to code only what is documented and signed by the doctor.