WHAT MAKES DOCUMENTATION CODEABLE:
  Legible: must be readable by all who need to access
  Complete: includes all elements needed for coding
  Accurate: reflects actual services provided
  Timely: completed at or near time of service
  Authentic: signed by the provider with credentials and date

PHYSICIAN DOCUMENTATION ELEMENTS:
  Chief complaint: reason patient presented
  History of present illness (HPI): duration, severity, timing, quality
  Review of systems (ROS): body systems reviewed
  Physical examination: body areas and organ systems examined
  Assessment: diagnosis (definitive or working)
  Plan: treatment plan, orders, follow-up

QUERY PROCESS:
  When: documentation is ambiguous, conflicting, or incomplete
  Who: CDI (Clinical Documentation Improvement) specialist or coder
  How: compliant query (non-leading, multiple choice or open-ended)
  
  VALID QUERY SCENARIOS:
    Diagnosis documentation present but no code exists → query for specificity
    Signs/symptoms present but no diagnosis documented
    Conflicting documentation between providers
    Possible or probable conditions after study → query for confirmation
  
  INVALID (LEADING) QUERIES:
    Suggest specific diagnosis not supported by clinical indicators
    Pressure physician to document higher severity without clinical basis

BODY SYSTEMS:
  Integumentary: skin, hair, nails, sweat glands
  Musculoskeletal: bones, muscles, tendons, ligaments, cartilage
  Cardiovascular: heart, arteries, veins, capillaries
  Respiratory: nose, pharynx, larynx, trachea, bronchi, lungs
  Digestive: mouth, oesophagus, stomach, intestines, liver, pancreas
  Urinary: kidneys, ureters, bladder, urethra
  Reproductive: gender-specific organs
  Nervous: brain, spinal cord, peripheral nerves
  Endocrine: glands producing hormones (thyroid, adrenal, pancreas)
  Immune/Lymphatic: lymph nodes, spleen, thymus

DIRECTIONAL TERMS:
  Anterior/Posterior: front/back
  Superior/Inferior: above/below
  Medial/Lateral: toward/away from midline
  Proximal/Distal: closer/farther from point of attachment
  Bilateral: both sides | Unilateral: one side

PROCEDURE SUFFIXES:
  -ectomy: surgical removal (appendectomy = remove appendix)
  -otomy: incision into (laparotomy = incision into abdomen)
  -ostomy: create opening (colostomy = opening in colon)
  -plasty: surgical repair (rhinoplasty = nose repair)
  -oscopy: visual examination (colonoscopy = examine colon)
  -gram: record/image (electrocardiogram = heart electrical record)
  -graphy: process of recording (echocardiography)