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The cases were confirmed by documentation of the postnatal diagnosis and narrative descriptions of abnormalities in the medical records.
Our patient presented with clinical features of adrenal insufficiency with hyperpigmentation (Addison's disease), which was confirmed by documentation of low serum cortisol and elevated plasma ACTH.
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Coders are instructed that when a condition is suggested by diagnostic test results, they should only code the condition if it has been confirmed by physician documentation.
In brief, new cases of lymphohaematopoietic (LH) cancers occurring through 2006 were identified using national mortality and cancer incidence registries and, additionally, for the Australian study, by self-report (n=3) if confirmed by medical documentation.
The diagnosis of IPA was confirmed by (1) documentation of abscess within the iliopsoas muscle by either PCD or surgery; or (2) classic CT or MRI finding of IPA with compatible clinical presentation, laboratory data, and blood cultures.
Eligible participants were HIV-positive and were either: starting ART for the first time; making a change to their regimen; or having self-reported adherence problems (confirmed by provider documentation and/or HIV RNA >1,000 copies/mL).
Further eligibility criteria were at least 1 episode of AF confirmed by ECG and documentation of at least 1 ineffective AAD treatment, including β-blockers.
It was further confirmed by reviewing medical records documentation.
Diagnosis must be confirmed by needle biopsy or by radiographic documentation that the mass lesion is increasing in size in the absence of treatment.
Further, parental report of allergic rhinitis or hay fever was not confirmed by chart review, but primary care physician documentation of these diagnoses may not be the gold standard because it is likely to vary by individual practice.
The queries were applied to two similar medium-sized applications available for each language, and the results were confirmed by manually investigating the source code and available documentation.
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