A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux
Which problem with documentation might have caused the lack of reimbursement?
1. The client's record contained an incorrect DRG.
2. The client was charged for an ECG.
3. A code cart was opened and the client was charged for medications opened but not used.
4. The physician made a diagnostic mistake.
Correct Answer: 1
Rationale 1: Documentation helps a facility receive reimbursement from the federal government. The client's clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Coded diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses.
Rationale 2: This would not necessarily result in the problem related to reimbursement because it is a reasonable diagnostic test to perform in this situation.
Rationale 3: This would not necessarily result in the problem related to reimbursement.
Rationale 4: This would not necessarily result in the problem related to reimbursement.
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