Clinical coding is reliant on the quality of the documentation in EPR. The coders count on our clinical teams to clearly document what is treated or investigated during a patient's stay. So remember be Specific, Complete, Accurate and Relevant.
Specific - For example: Don't just write diabetes - is it type 1 or 2?; If a patient has been admitted with an injury tell us the cause; If you've injected into the spine - which area of the spine have you injected into?
Complete - Clearly record all diagnoses (including comorbities) and procedures as well as any complications
Accurate - It may sound simple but please don't record conditions if the patient doesn't have them
Relevant - Only document conditions that are relevant to the patient's stay