HIM incompleteness checks flag a missing discharge summary for a completed inpatient stay that is ready for final abstracting. What is the coder's compliance-minded response?
Select an answer to reveal the explanation.
Short Explanation
The discharge summary is the inpatient story's last chapter — if HIM says it is missing, you do not write fan fiction from flowsheets. Completeness checks exist so final abstracts wait for that required document. Fix the deficiency, then finish coding.
Full Explanation
Discharge summaries are core components of the inpatient health record and often required for a complete legal and clinical record. HIM incompleteness processes identify missing summaries so coding and abstracting are not finalized against an incomplete chart. Coders must not author clinical discharge narratives or treat short stays as exempt from documentation rules. Resolving the completeness deficiency before final abstracting supports regulatory and facility standards.