What is the first step in an inpatient record review?

Verifying the correct assignment of the principal diagnosis serves as a foundational step in an inpatient record review. The principal diagnosis is the condition established after study to be chiefly responsible for the patient's admission to the hospital. Correctly identifying and assigning this diagnosis is critical as it influences a multitude of factors, including treatment decisions, billing, and statistical data related to patient health outcomes.

Ensuring that the principal diagnosis is accurate sets the stage for subsequent steps in the review process. If the principal diagnosis is misidentified, all follow-up evaluations, including treatment plans and assessments of patient outcomes, could lead to inaccurate conclusions and potentially poor patient care. This initial verification is essential for maintaining the integrity of the patient's medical record and ensuring compliance with healthcare standards and regulations.

After confirming the principal diagnosis is appropriate, the reviewer can effectively move on to other components of the record, but without this initial verification, the entire review process may be compromised.