Re: Coding System
Using EHR's poses challenges that stymie medical record abstractors yet hospital reimbursement depends on accurate reporting. Documentation is often duplicative as everyone is diligently documenting, and none of them at the same minute and second, while the auditor drowns in information. No longer is it simply finding "a needle in the haystack". It is how many needles of the same information are there, and which among the needles is the accurate one. If the correct response isn't found, or doesn't exist, compliance is lower ( as are, possibly, Administrator's bonuses).
How does a physician manage the care of a patient with a diagnosis of "intracerebral hematuria?"