Nurses

Informational Needs

  1. A copy of select portions of previously coded and billed inpatient charts. Please see Documentation Requirements page for specific information.
  2. The number of charts required for a good statistically correct study is dependant on the size of the facility and several other site-specific factors. In general for hospitals with less than 100 beds we recommend between 25 and 50 charts; for hospitals with over 100 beds we recommend between 50 and 100 charts.
  3. The charts should be randomly selected and should represent all services provided by the hospital, i.e., Medical, Cardiac, Oncology, OB/GYN, Orthopedic, etc.
  4. Charts should, if possible, represent each inpatient coder on staff.

Documentation Requirements for Inpatient Coding Review


Chart Transmittal Log – List of charts being sent to HCCS for audit.

Information needed from each chart:

  • Face sheet (demographics)
  • All physician notes, dictated or hand-written
  • All orders
  • History and Physical
  • All progress notes
  • All lab reports
  • Emergency room record (if patient came through ER)
  • All reports of procedures
  • Operative report
  • Pathology report
  • All consults
  • All x-ray reports
  • Discharge instruction sheet (Nurses)
  • Discharge summary (if available)
  • UB92
  • Abstract / Coding Summary

Do not send:
  • Nurses’ reports
  • Medication reports
  • PT, OT, ST notes, etc.
  • Any ancillary note