Q&A How do you code handwritten medical records?

[Carmen]

Last week I was given a test for an anesthesia coding position. The test was timed and it included 26 cases for which 12 were handwritten doctors notes. It was very difficult for me to comprehend some of the terms and abreviations. My question is; how can I prepared myself to read and understand doctor's handwritten medical records in order to code them in an accurately manner?

 

[Alicia Scott]

I have had a lot of training in this Carmen. Especially recently. I just completed 150 handwritten charts for a practice session. It took me a while to finish.
Some key points:
You need to use an overview of information not just an assessment or plan. Check medication lists to confirm what you are thinking. Also your knowledge of what is being done to the patient helps. So if a procedure is being done for the heart and you know those terms they will jump out at you. In addition, learn your medical abbreviations. I know even when I was having to hand write patient histories and such in the ER being able to save time with abbreviations was essential. All and I mean ALL physicians do this. My Uncle a PA in the Air Force made a comment to me one time when I commented on having to read a physicians handwriting that is you had to write that much in one day your hand writing would suffer as well. It did in fact do that. I found that I got worse through the years. Your brain works faster then your hand can write.

So, look at the entire encounter not just the dx. Learn as much as you can about what procedures are being done. Know your abbreviations.

 

[Carmen]

Thank you Alicia these are very good ideas.....I believe the surprise of handwritten notes, gave me a litte anxiety. I would have love to be exposed to these kinds of scenarios while I study advanced coding. I knew that the cases were for anesthesia coding...the difficulty was in the number of diagnosis and the qualified modifiers....the time and the procedure were not difficult, but everything else was very hard to read....I need to practice, practice, practice...sorry just venting.

 

[Alicia Scott]

I didn't feel like you were venting. That is what we are here for. It is nice to have a place where you can talk about what you are experiencing and there will be others who have been right there were you are.

I was thinking yesterday I will go get medical records on myself and family....with permission, take off the names and use them for practice so students have access to current encounters to look through.

On a side note, as doctors move to EMRs you will see less and less handwritten notes.

 

[Carmen]

Hi Alicia,
You are absolutely correct EMRs is going to eliminate a lot of this. That makes me feel much better.
Thanks for your support Alicia.