Sample medical record entry

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Question

1. Write a sample medical record entry that a coder might receive in the field to code from. In that record entry, be sure to give yourself something to query the physician about. For example, provide a treatment that doesn't align with diagnosis, explain conflicting or inconsistent information, assign a diagnosis without proper validation, etc.

2. Write the query to the physician. Be sure to be very specific about what you are looking for in your query. Be sure to include all of the necessary elements.

Reference no: EM133877650

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