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Help w/Documentation

  1. Default Help w/Documentation
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    I am new to coding Psychiatric inpatient charts and I was told to code all "history of" diagnosis that the nurses have pulled from a patient's old records and put on the face sheet (s/p hysterectomy, appendectomy, gallbladder removal, cataract removal).
    The doctor is not documenting the majority of the "history of" diagnoses in his current physician orders which is where I code from.
    Also the doctor documents an up arrow lipids. He doesn't document hyperlipidemia so I was told not to code this. Any clarification would be appreciated.

  2. Smile
    I would recommend you query the physician on what he/she means by (Up arrow) lipids if you have a question as to what that means. Having a one time elevated reading does not neccessarily mean you have that disease. If I had an elevated blood pressure reading one time, I would certainly be upset to be diagnosed with hypertention when the reason for that I was in the flight or fight moment in time.

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