Final answer:
Before signing off on a medical record, a coding specialist should review and confirm important information with the team, including procedure details, equipment counts, patient identity, and critical events. This helps ensure accurate coding.
Step-by-step explanation:
Before signing off on a medical record, a coding specialist should:
- Review the items aloud with the team to ensure that the name of the procedure, needle/sponge/instrument counts, specimen labeling, and equipment issues are accurately recorded.
- Confirm the identity of all team members, as well as the patient's identity, surgical site, and procedure.
- Have the surgeon review critical steps, operative duration, anticipated blood loss, and any concerns specific to the patient. This information is vital for coding procedures accurately.