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Do coders take notes?

lita1981

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I wanted to know if medical coders take notes on specific information in the medical record as they review the record to assign the correct codes.
 

CynthiaLarson

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I have done that in the past. Specifically when coding IR procedures. I will highlight or note down the starting point and end point so as to keep me from having to re-read the report several times.
 

Ruth Sheets

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It seems to me, you should do this if it helps you get to the right codes more efficiently. You are a professional and you should allow yourself to work in a way that improves your accuracy and efficiency. You should adhere to your workplace policy on disposing of your notes to prevent a breach of privacy in regards to the patient, of course, but I imagine most of the time you would not be writing down the patient's personal information - just codes, names of diseases, procedures, body organs, etc. on scratch paper.
 
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