You have now learned about diagnosis and procedural coding. You may have seen a variety of methods used to document the services provided to a patient. In Chapter 2 of your text, the Problem-Oriented Record (POR) is discussed. This is meant to be a thought-stimulating, learning activity, that may have different answers from the perspective of a coder working for a surgical facility versus a coder who is coding E & M (Evaluation and Management) services through a physician’s office.

Explore the benefits of standardizing medical documentation in the Problem-Oriented Record.

Include the following aspects in the discussion:

· Explain the importance of a clear SOAP (subjective, objective, assessment, plan) note to the medical coder.

· Discuss how you will recognize information that is subjective versus information that is objective (especially if the note is not in a SOAP format.)

· Indicate in which area the coder will find the current diagnosis for today’s service

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