Guided Notes

The Medical Record: What Coders Read

The documents in a patient's chart — SOAP notes, H&P, operative reports, discharge summaries — and how to read them to find what's codable.

The golden rule of coding

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Coders code from documentation — never from assumptions, verbal comments, or the charge sheet alone.

'If it isn't documented, it wasn't done.'

The medical record is a legal document. It must show who saw the patient, why, what was found, what was done and the plan — authenticated (signed) by the provider. Your codes must be supported by it in case of an audit.

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