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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