Guided Notes
The Medical Record: What Coders Read
The documents in a patient's chart — SOAP notes, H&P, operative reports, discharge summaries — and how to read them to find what's codable.
The golden rule of coding
Slide 1 / 6Coders code from documentation — never from assumptions, verbal comments, or the charge sheet alone.
'If it isn't documented, it wasn't done.'
The medical record is a legal document. It must show who saw the patient, why, what was found, what was done and the plan — authenticated (signed) by the provider. Your codes must be supported by it in case of an audit.