What should a coding professional do if a lab report shows a staph infection but there is no mention in the physician's documentation?

When a lab report indicates a staph infection but this finding is not documented in the physician's notes, the best course of action for a coding professional is to query the physician. This step is essential because accurate coding relies on comprehensive and precise documentation. By consulting the physician, the coder seeks clarification on whether the staph infection is relevant to the patient's diagnosis or treatment, which must be reflected in the medical record for accurate coding.

This process ensures that all pertinent information is included, helping to maintain the integrity of the coding process and ensuring compliance with applicable coding standards and regulations. In situations where coding is based on documented evidence, it is critical to ensure that the documentation accurately reflects the patient's condition, which in this case means confirming whether the staph infection should be recorded in the official medical record. This practice aligns with the principles of coding accuracy and accountability within healthcare settings.