Health Information Technologies and Processes

Coders Documenting in Health Record

  • 1.  Coders Documenting in Health Record

    Posted 04-07-2020 13:38
    Is there any legislation or regulation that states coding professionals may create problem lists of diagnoses and/or document diagnoses in the health record?  Feel free to reply directly,  Thank you!

    Roberta Peters
    Regional Vice President, Coding Integrity Solution Sales
    Streamline Health

  • 2.  RE: Coders Documenting in Health Record

    Posted 04-08-2020 13:07
    Hi Roberta:

    I am not aware of any legislation pertaining to problem list ownership or maintenance. I would recommend that you peruse AHIMA's 2019 Practice Brief (PB) regarding problem list. It's available to AHIMA members via Body of Knowledge (BoK). The PB suggests that "Organizations should develop a policy that outlines who can make entries into the problem list and that determines if the entries are to be considered as clinical documentation to guide CDI and coding practices." It also adds "...organizations may decide to allow CDI and/or coding professionals to update and/or remove problem list diagnoses when supported by provider documentation in response to a query."

    Best regards.



    Marina Kravtsova RN, CDIP, RHIA, CCS, AHIMA-approved CDI Trainer
    Ambulatory Clinical Documentation Specialist
    UChicago Medicine