Medical Record Abstraction Abstracting information from medical records for coding purposes is a critical task in medical coding. Medical Record Abstraction involves extracting relevant clinical details from patient records to assign accurate diagnostic and procedural codes. How to Abstract Information from Medical Records? Here’s a structured approach to abstracting information from medical records for coding: Understand the Purpose Review the Entire Medical Record Identify Key Elements Code Assignment Follow Coding Guidelines Document Findings Continuous Education 1. Understand the Purpose Before starting the medical record abstraction process, ensure you have clarity on the purpose of coding. Are you coding for reimbursement, research, or statistical analysis? Each purpose may require a slightly different approach or level of detail. 2. Review the Entire Medical Record Begin by reviewing the entire medical record thoroughly. This includes admission notes, progress notes, physician orders, consultation reports, diagnostic test results, operative reports, discharge summaries, and any other relevant documents. 3. Identify Key Elements Pay close attention to key elements that impact coding, including: Patient demographics: Ensure accuracy in patient identifiers, such as name, date of birth, and medical record number. Dates of service: Note the dates of admission, discharge, and any relevant procedures. Chief complaint: Understand the … Continue reading Abstracting from the EHR