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Table 1 List of documentation sources coders reported using

From: Barriers to data quality resulting from the process of coding health information to administrative data: a qualitative study

Types of Documentation
• Discharge summaries or ambulatory care records
• Triage sheets
• Transfer summaries
• Service transfers
• Progress notes (physician or nurses)
• Nursing assessments
• Operative reports or peri-operative reports
• Referral letters
• Consultations
• Doctor orders
• Pathology reports
• Laboratory test results
• Microbiology reports
• Diagnostic imaging reports
• X-Ray reports
• Radiology reports
• Haemodialysis records
• Transfusion records
• Special procedures
• Prescription orders
• Patient histories
• Patient physicals
• Admission histories