| Record Review |
| Directions: Please review the medical record for this week. Upon review of the medical record you will abstract and code applicable diagnosis and procedures from the medical record. |
| Patient Name |
| Chief Complaint: |
| Signs and Symptoms: |
| Provisional Diagnosis: |
| Consultations: |
| Were there any laboratory testings? If so list here. |
| If the results were abnormal place data here. |
| Were there any radiology testings, is so place data here. |
| If the results were abnormal place data here. |
| Any other diagnostic studies that were apart of the patient record place here. |
| If the results were abnormal place data here |
| Listed medications: |
| Procedures- invasive only: |
| Pathology Findings: |
| Applicable diagnoses-Remember to use your UHDDS definitions for this portion of the record review |
| Diagnosis Numerical code | Narrative Description |
| 1.) | | | | | Principle Diagnosis |
| 2.) | | | | | Additional Diagnosis |
| 3.) | | | | | Additional Diagnosis |
| 4.) | | | | | Additional Diagnosis |
| 5.) | | | | | Additional Diagnosis |
| 6.) | | | | | Additional Diagnosis |
| MS-DRG | Narrative Description |
| Applicable procedures- Remember to use your UHDDS definitions for this portion of the record review |
| Procedural Numerical code | Narrative Description |
| 1.) | | | | | Principle Diagnosis |
| 2.) | | | | | Additional Procedure |
| 3.) | | | | | Additional Procedure |
| 4.) | | | | | Additional Procedure |
| 5.) | | | | | Additional Procedure |
| 6.) | | | | | Additional Procedure |
kgef13
recordreviewworksheet.xlsx
