Zolemba zachipatala ndizofunikira kwa ntchito yolemba mankhwala . Udindo umodzi waukulu wa zolemba zachipatala ndiko kusandutsa chidziwitso m'mabuku a zachipatala kuti mudziwe momwe mungagwiritsire ntchito. Mukamalemba zolemba za dokotala, nkofunika kuti musaganize. Ngati simukudziwa kapena simukudziwa, nthawi zonse mumvetsetse dokotala.
Pali mitundu iwiri ya zolemba zachipatala zomwe zimathandiza kulembera kachipatala mu zolembera ndi zolemba za ofesi ndi zolemba.
- Zolemba za Office zimaphatikizapo chifukwa cha wodwalayo, zizindikiro, matenda ndi matenda, zofufuza za dokotala, ndondomeko ya mankhwala, ndi ndondomeko yotsatila.
- Zolemba zogwiritsira ntchito zimaphatikizapo chithandizo choyambirira, chithandizo cha postoperative, chithandizo ndi njira zomwe zimachitika, ndi kufotokoza zonse zomwe zinachitika, nthawi, ndi pambuyo pake.
Pofotokozera zolemba, onetsetsani kuti zolemba zonse zolembedwa ndi dokotala zimathandizira kupeza matenda ndi njira. Komanso, onetsetsani kuti matendawa amapereka thandizo lachipatala pazinthu zomwe zili muzolembazo.
Perekani Ma ICD-10 Ma Code ndi Ma CPT
Wodzitetezera wa zachipatala ayenera kupereka zizindikiro kuti adziwe ndi njira zomwe zilembedwera m'makalata odwala.
Kuzindikira Madilesi
Zizindikiro za kugwiritsidwa ntchito zimachokera ku Dongosolo la Maiko Lonse la Matenda (ICD). Kusindikiza kwamakono ndi ICD-10 . ICD-10 inayendetsedwa ndi Centers for Medicare ndi Medicaid Services (CMS) pa October 1, 2015, m'malo mwa ICD-9.
Mapulogalamu operekedwa kuyambira pa 1 Oktoba 2015, ayenera kuwerengedwa ndi zida za ICD-9 ngakhale ngati misonkhano siidaperekedwa kufikira pa 1 Oktoba 2015. Ntchito zothandizidwa pambuyo pa kukhazikitsa ICD-10 pa October 1, 2015, ziyenera kuwerengedwa ndi ICD -10 zizindikiro.
Makalata Otsatira
Makhalidwe a ndondomeko amachokera m'buku la Current Procedural Terminology (CPT) monga momwe amachitira ndi American Medical Association (AMA).
Buku la CPT limatchula zizindikiro za CPT , njira zomwe zimagwirizanitsidwa ndi madokotala, chipatala chachipatala, ndi malo opangira opaleshoni (ASC). Zolemba zachipatala sizinatchulidwe m'buku la CPT. Zizindikiro izi zimapezeka m'buku la ICD-10-PCS, m'malo mwa ICD-9 Voliyumu 3.
Khalani Pano pa Zotsatira Zokonzera
- Pitani ku webusaiti ya AMA. Tsambali limapereka zowonjezera, zowonjezera, zosintha, ndi zowonjezera ku buku lolembera. Webusaiti ya AMA imathandiza anthu kuti azidziwa zamaluso komanso kuti azidziwa bwino ntchito zawo, zomwe zimawathandiza kukonza ndi kusunga luso lawo, ndikudziŵa bwino malamulo ndi malamulo, ndikudziwitsani kuti ntchito yawo ikhale yabwino. AHIMA ndi AAPC ali ndi mawebusaiti omwe amapereka mauthenga apamtima, olongosoka komanso othandizira nthawi zonse kwa makalata ochipatala nthawi zonse.
- Pezani zosintha za CMS. CMS imafalitsa zosinthika ku webusaiti ya CMS pachaka. Ikuperekanso chithandizo chothandizira, malamulo ndi malamulo, komanso nkhani za Medicare. Ogwira ntchito a Medicare ndiwonso gwero labwino lokonzanso nthawi zonse. Makondwe amatha kulemba pa listervs.
- Lumikizanani ndi zolemba zina. Kulembera ndi malo akuluakulu, zolemba imodzi sizingathe kudziwa chirichonse chomwe chingadziwe za kulembedwa. Nthawi zina zizindikiro zimathamangira ku zinthu zomwe zimafunikira thandizo lina. Coders akhoza kukhala zothandiza kwambiri, nthawi zambiri zothandiza kwambiri, kwa wina ndi mzake. Ngakhale kuti nkhani yogawidwa ndi yofunikira, nkofunika kusamala za malangizo kapena thandizo lomwe likuvomerezedwa. Kulemba masewera ndi malo amodzi omwe mungakhale kutali. Aliyense akhoza kuyankha mafunso pa zolemba maofesi omwe angayambe kulembetsa malamulo kuti aswe malamulo olembera.
- Werengani malangizo a CPT. Malangizo mu bukhu la codet ya CPT ndipadera pomwepo kuti athandizire ma coders ndi zonse zofunika zokhudzana ndi kulembedwa monga momwe angapezere ma code, magulu a zizindikiro, malongosoledwe a zizindikiro, zikho zomwe zingathe kuwerengedwera pamodzi ndi malamulo omwe ayenera kutengedwa okha.