2-1 Short Paper: Patient Record Analysis

Instructions

In this short paper, you will identify missing or incomplete sections of a healthcare organization’s sample patient record. Then you’ll discuss how the errors occurred in the record and who is responsible for them, as well as what the potential impact of these errors might be on the billing and coding process of the organization. Use the following resources to help you answer the critical element questions:

To complete this assignment, review the Module Two Short Paper Guidelines and Rubric document

Overview: For this short paper, you will identify missing or incomplete sections of a healthcare organization’s sample patient record. You will then discuss how the errors occurred in the record and who is responsible as well as what the potential impact of these errors might be on the billing and coding process of the organization.

Prompt: First, review the index of current and accurate ICD-10-CM/PCS guidelines and codes in ICD-10-PCS Coding Guidelines and ICD-10-CM Coding Guidelines. Also review the Glossary of Terms document. All resources are linked in the 2-1 Short Paper assignment in the module.

Next, carefully review the Inpatient Face Sheet document for inconsistencies and coding errors (e.g., clinical indicators not addressed by the physician, contradicting physician diagnoses) and address the following:

 Record: What are the missing or incomplete sections of the patient record?

 Errors: Who is responsible for ensuring all documentation is within the record, and what do you think is the cause of the missing documents? Support your answer with resource citations.

 Impact: What is the potential impact of these errors on the billing and coding process of the organization?

Support your responses by referencing the patient record and the Modules One and Two resources. 

Rubric

Guidelines for Submission: The short paper should be 2 to 4 pages in length with double spacing, 12-point Times New Roman font, one-inch margins, and citations in the current APA style.



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