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You have now learned about diagnosis and procedural coding. You may have seen a variety of methods used to document the services provided to a patient. In Chapter 2 of your text, the Problem-Oriented Record (POR) is discussed. This is meant to be a thought-stimulating, learning activity, that may have different answers from the perspective of a coder working for a surgical facility versus a coder who is coding E & M (Evaluation and Management) services through a physicianβs office.
Explore the benefits of standardizing medical documentation in the Problem-Oriented Record.
Include the following aspects in the discussion:
Β· Explain the importance of a clear SOAP (subjective, objective, assessment, plan) note to the medical coder.
Β· Discuss how you will recognize information that is subjective versus information that is objective (especially if the note is not in a SOAP format.)
Β· Indicate in which area the coder will find the current diagnosis for todayβs service
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