As part of your internship with South Padre Medical Center, you are working under the supervision of the coding supervisor, Marla Kauffman. The clinic’s CDI Director, George Bowman, wants to better educate the physicians on the importance of accurate and complete medical records.  Therefore, George is planning on beginning a series of education sessions every month. He has asked Marla to prepare a presentation on proper documentation. 

Marla thinks that helping with this presentation would be a wonderful opportunity for you during your internship so that you can learn how to improve clinical documentation by identifying some key elements that are missing or unclear inpatient documentation. Marla’s plan for the presentation is to present some cases and examples where the coders did not have the information they needed to code. Marla has asked you to assist in preparing for this presentation by identifying any missing or unclear information from four patient records and drafting a PowerPoint presentation on your findings. 

Because you are a new coder, Marla also thinks it would be helpful for you to research the importance of proper documentation and ways to ensure documentation is complete and accurate and then include information from your research findings into your PowerPoint presentation.