Question: For each of the documents listed below, identify whether it can be directly used for coding or should be reviewed but not directly used for
For each of the documents listed below, identify whether it can be directly used for coding or should be reviewed but not directly used for coding. Select all that apply.
Can be directly used for coding
A Diagnosis in the CPOE by the attending physician
B Consults without conflicting documentation
C OR reports preoperative diagnosis
D Abnormal laboratory results
E Clinical notes for BMI
F PNs by anesthesiologists
G Consults with conflicting documentation
H Family history in the H&P
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