Which term involves analyzing a patient’s medical history to extract coded data?

• A. Social Determinants of Health
• B. Video Conferencing
• C. Hearing Appliances
• D. Clinical Record Review

Answer: (D)

Analyzing a patient’s medical history to extract coded data is clinical record review. This involves going through the patient’s chart—provider notes, diagnoses, medications, lab results, past hospitalizations, and treatment plans—to pull out information that can be entered as standardized data elements. These elements are then coded using recognized schemes (like ICD-10-CM for diagnoses) so the information is consistent, verifiable, and usable for care planning, reporting, and billing in home health assessments. This approach is essential because much of what we need to document for OASIS comes from the chart, not just from what the patient can tell us at the moment. The other options don’t describe this data-abstraction process: they relate to communication methods, devices, or social factors rather than extracting and coding medical history information.