In Inpatient coding, medical coders have to see lot of patient information. I have shared all the specific reports for coding inpatient charts in my previous post, inpatient coding features and characteristics.

Today I am sharing a inpatient medical coding charts, which is coded with ICD 10 codes and DRG codes. This charts will include only

History and physical exam
Progress Notes
Discharge Summary

Since, these are the key reports I am sharing only these reports, hope this report will help you learn about Inpatient coding.

Inpatient Medical coding Example chart 1

Dictated History and physical exam

Date of Admission: 01/26
Date of Service: 01/26
Admission to the Trauma Service

HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old man who fell down
some stairs. He had a laceration on the back of his head and blunt trauma to
the left lower lateral flank area. ER physician, Dr.,
evaluated the patient and said that he developed a tense hematoma about the size
of a grapefruit above his iliac crest in the abdominal wall. There was some
extravasation of dye. CT head and neck, nonacute. There was no finding of
acute visceral injury. The patient says gallbladder removed. Incidental
finding of a solid renal mass in the left lower pole of the kidney. Left flank
mass is seen on the CT and possibly would be amenable to IR embolization, should
it not stop enlarging. The patient has abdominal binder on at this time. He is
not complaining of any particular pain from that area. There are no broken ribs
and his left kidney appears to be not involved in the process.

The patient had a CABG and left inguinal hernia repair in the last 12 months.
One month ago, Dr. performed an open left inguinal herniorrhaphy here at
Hospital. The patient takes allopurinol, atorvastatin, melatonin,
enalapril, and low-dose aspirin. Allergies includes ampicillin and clindamycin,
unspecified reaction. The patient will be admitted to follow this abdominal
wall hematoma.

PAST HISTORY: As above.

MEDICATIONS: Discussed.

ALLERGIES: NOTED.

FAMILY HISTORY/SOCIAL HISTORY: Noncontributory.

REVIEW OF SYSTEMS: No URI or UTI. BA 212.

PHYSICAL EXAM: GENERAL: Patient in bed 3 in the ER, conversant, appropriate.
VITAL SIGNS: Blood pressure 123/98, pulse 100, pain 4/10, O2 saturation 97% on
room air, respiratory rate 17, unlabored; temp 98.4.
HEENT: Scalp laceration, occipital area, closed by ER physician and not
bleeding.
NECK: Supple. Trachea midline. No crepitus.
EXTREMITIES: Upper extremities, normal sensation, motor, pulse. Ribcage and
sternum nonacute. Lower extremities, normal sensation, motor, pulse.
LUNGS: Clear bilaterally.
HEART: Regular rate and rhythm. No JVD or cyanosis.
ABDOMEN: Benign. Left flank, grapefruit sized lower posterolateral ecchymotic
mass corresponding to hematoma. It is in the abdominal wall, not expanding.
RECTAL: Negative.
GENITALIA: Normal male.
NEURO: GCS 15, nonfocal.

DIAGNOSTIC DATA: White blood count 12,500, hematocrit 45.8, platelets 183,000.
Electrolytes negative. Total bilirubin 0.4, albumin 3.3. Liver function tests
normal except for mild elevation of SGOT 39. Lactate 2.6. INR 1.0. Urinalysis
clear, no RBCs or blood. Blood type O positive.

ASSESSMENT: The patient will be admitted to the Trauma Service. H and H will
be obtained at midnight in 0400 hours or 0500 hours. The patient will be placed
on his usual medications except for aspirin. We have decided to hold off on
platelet transfusion at this time. IR is aware of the patient and if he
decompensates, he will be taken there for embolization.

Dictated Discharge Summary

Date of Admission: 01/26
Date of Service: 01/27
DIAGNOSIS: Mechanical fall, left flank hematoma.

HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old man who fell down
stairs last night. He developed a left lower posterolateral hematoma over his
iliac crest. This was in the abdominal wall and not involving the
intraabdominal compartment. The patient takes aspirin following a CABG
procedure earlier last year. More recently, the patient underwent an open left
inguinal hernia repair by Dr. at Hospital.

The patient had stable vital signs. In the emergency room, he was awake and
alert. CT scan with IV contrast suggested extravasation and abdominal binder
was placed.

HOSPITAL COURSE: The patient was admitted to the Trauma Service and over the
course of the night, serial hematocrits showed no appreciable drop in his red
blood cell level. The patient was ambulating well in the hall, taking clear
liquids without problem. This morning, he did complain of a left pinpoint pain
in the 7th or 8th rib just off the sternum. Re-review of the chest film shows
no obvious rib fracture and most likely, the patient had some issue with his
costochondral joint or a cracked rib. He has no ventilatory or respiratory
issues and other than being sore when you press on it. It is not causing any
problems at this point. The patient has incentive spirometry at home.
The patient will be able to be discharged on his usual medications which include
melatonin 5 mg p.o. at bedtime, Coenzyme Q10, milk thistle, turmeric root
extract, Mylanta p.r.n., gabapentin 300 mg at bedtime, Lipitor 40 mg p.o. daily,
enalapril 20 mg p.o. daily, allopurinol 300 mg p.o. daily, and various vitamins.
The patient is on low-dose aspirin and he will abstain from this for a week, at
which point he may resume. The patient will follow up with Dr.
, his primary care physician, early next week. He is to report any
lightheadedness, paleness, expansion of the left posterolateral flank hematoma,
or breathing issues immediately to Dr. until he sees his
primary care physician.