Data
A medical coder closely reviews a patient's diagnosis, treatments, and other pertinent data from the chart, including doctor names and procedure dates. The medical coder then starts converting the doctor's notes into usable medical codes using ICD-10 and CPT code books.
The general health and well-being of a patient are ascertained from lab data. Numerous factors can influence a patient's test results and lab values, but the most prevalent ones include age, gender, race, medications used, and the existence of any underlying conditions.
Making educated clinical decisions as a nurse requires understanding the various typical lab readings. Tests for diagnosis and laboratory work are useful instruments that offer vital information about the patient.
Snell, E. (2018). What are the Benefits of Clinical Documentation Improvement (CDI)?. HER Intelligence. https://ehrintelligence.com/features/what-are-the-benefits-of-clinical-documentation-improvement-cdi
