Summary
Review and abstract medical records from inpatient, outpatient, neonatal, maternal, and specialty care settings. Identify and abstract key clinical and demographic information relevant to birth defects. Assign, confirm, or change ICD-10-CM diagnosis codes using Program rules and clinical guidelines. Translate clinical descriptions and operative notes into appropriate codes. Identify omissions, inconsistencies, or unclear documentation and flag issues as needed. Accurately enter abstracted data into designated systems and maintain documentation. Coordinate with other abstractors and participate in meetings and trainings. Follow all QA procedures, respond to feedback, and correct errors within required timeframes. Maintain confidentiality and comply with HIPAA and state privacy requirements.