To determine the reason for an encounter and the conditions treated, coders should review the __________ because providers will often document additional information about a condition elsewhere.

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The selection of the patient record in its entirety as the correct answer reflects the importance of a comprehensive review when determining the reason for an encounter and the conditions treated. A patient’s medical record contains various components, including progress notes, medication lists, past medical histories, lab results, and more, which can all provide critical insights beyond just the primary diagnoses.

By reviewing the entire patient record, coders can uncover additional documentation or annotations made by providers that may explain underlying conditions, clarify the reason for the visit, or provide context about the patient’s health status. This thorough approach ensures that the icodification of the patient's case is accurate and captures all relevant clinical information necessary for proper coding and billing.

While other options might contain useful information, they do not offer the comprehensive view that a complete patient record provides. For instance, a health insurance claim focuses mainly on the billed services; a discharge summary and face sheet might contain summary data but could miss detailed notes in the records; and a list of diagnoses and procedures does not capture the nuances or additional context found in more detailed documentation. Therefore, a holistic examination of the entire patient record is essential for effective coding.

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