Don’t jump to conclusions about documentation

These days, documentation improvement and compliance are at the forefront of coders' minds. In some cases, coders are led completely astray by bad data and physician documentation that isn't entirely accurate. Robert S. Gold, MD, emphasizes that it’s important for coders to always look at the larger clinical picture in the medical record—not just a documented laboratory result or change in vital sign. Gold applies this philosophy and examines a number of conditions, including anemia, acute kidney injury, congestive heart failure, and myocardial infarction.

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