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List the diagnoses. Abstract all information from the patient’s medical record and all conditions that were treated and those that affect treatment according to ICD-10-CM coding guidelines. Code conditions abstracted using ICD-10-CM coding book and enter your data into the Health Information Management Coding Worksheet.
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2. List the procedures. Abstract all significant operations and procedures performed during the admission from the patient’s medical record. Code all significant procedures using ICD-10-PCS procedure codes according to ICD-10-CM coding guidelines. You will enter your information into the Health Information Management Coding Worksheet.
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3. Abstract any other information required from the patient’s record, including age, sex, discharge status, and length of stay, to completely fill out the Health Information Management Coding Worksheet.
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