diagnosis on discharge forms

joyce_williams_30088joyce_williams_30088
in CDI Talk Archive
when pt's are discharged from our facilities, the MD, NP or PA fill out a coc form(continuity of care form). At times, diagnosis are added to this form. Can these diagnosis be coded? Physicians at times answer our query's on these forms. Any information will be helpful. Thanks to all in advance.

Comments

  • rmhosler1rmhosler1
    edited May 2016


    I believe it depends on the policies the executive medical committee has
    drafted at your hospital. At our hospital the form is optional for the
    physicians. We do look at it as a tool only.


    Mary A Hosler MSN, RN
    Clinical Documentation Specialist
    Alumnus CCRN
    McLaren Bay Region
    1900 Columbus Ave.
    Bay City, Michigan 48708
    (989) 891-8072
    mary.hosler@mclaren.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug."- Samuel "Mark
    Twain" Clemens
  • robert.hodges2robert.hodges2
    edited May 2016
    My additional question is if this form is a part of your legal health
    record? If not, I would suspect you cannot code from it. Our providers
    are required to document any query response in the health record.
    Otherwise, it doesn't count.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS

    Clinical Documentation Improvement Specialist

    VHA CDI Council Member

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



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