MEMO

Memo

Memo

To:

From:

Date:

Re: Diagnosis and Procedure Codes Documentation

Background

According to recently conducted audit of medical records with a diagnosis of bacterial pneumonia, I have found that in 65% of the medical records, the diagnosis of bacterial pneumonia was not was supported by the documentation. This was discussed with other staff and they reported that the Medical Chief of Respiratory Medicine had told them that there are other ways to determine bacterial pneumonia other than a lab culture and they should just assign the code for bacterial pneumonia.

In personal appearance, it consists of a number of sheets of paper or cards and may be put ...