Sally Smith Is Reviewing an Inpatient Record for Coding

question 10

Multiple Choice

Sally Smith is reviewing an inpatient record for coding. She notes that the face sheet, diagnostic testing reports, and discharge summary contain different diagnoses. What should she do to code the diagnoses?

• A) Use the diagnoses on the face sheet.
• B) Select all the diagnoses on all three forms of documentation.
• C) Use the diagnoses on the discharge summary.
• D) Query the provider for clarification.

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Definitions:

Hallucinations

Perceptions in a conscious and awake state in the absence of external stimuli, which have qualities of real perception.

Alzheimer's disease

A progressive neurodegenerative disorder characterized by cognitive decline, memory loss, and behavioral changes.

Crohn's disease

A chronic inflammatory condition of the gastrointestinal tract, which is part of a group of conditions known as inflammatory bowel disease (IBD).

Asperger's syndrome

A developmental disorder affecting the ability to effectively socialize and communicate, considered to be on the high-functioning end of the autism spectrum.