Registered Health Information Administrator

The physician explicitly documents that a condition is not present at the time of admission.

The physician documents that the patient has diabetes that was diagnosed prior to admission.

The medical record documentation is unclear as to whether the condition was present on admission.

Patient is admitted to the hospital with acute abdominal pain. The attending medical physician requests a surgical consult. The consultant agrees to see the pat...

An established patient returns to the physician's office for follow-up on his hypertension and diabetes. The physician takes the blood pressure and references t...