Which of the following is/are a reason(s) why the discharge summary is not the only document from which codes are captured?
A)Coders may not have a discharge summary at the time of coding.
B)If the patient is in the hospital for a long stay, the attending physician will often be focused only on those diagnoses that occurred in the latter part of the stay.
C)Physicians list diagnoses that are not currently being treated and are only in the patient's history.
D)All of the options are correct.

Question

Quizplus · Accepted Answer

All of the options are correct. Coders may not have a discharge summary at the time of coding, the attending physician may focus only on recent diagnoses, and physicians may list diagnoses that are not currently being treated but are in the patient's history. Therefore, relying solely on the discharge summary may result in missed diagnoses or inaccurate coding.

Which of the Following Is/are a Reason(s) Why the Discharge