In which record component should the coder NOT capture diagnosis codes?

In the context of coding for diagnosis codes, the record component where coders should refrain from capturing these codes is nurse notes. Nurse notes are typically focused on the assessments and observations made by nursing staff, which may not directly include coding specifications related to diagnoses. Instead, diagnosis coding is generally derived from more formal components of the medical record, such as the exam, history, and consultation notes.

The exam and consultation components often contain detailed findings and specific diagnoses made by physicians, while the history includes past medical conditions that provide crucial context for current health issues. Coders usually derive diagnosis codes from these clinical documents, ensuring that the coding reflects the specific conditions addressed during the visit or encounter. Therefore, while nurse notes are essential for patient care and continuity, they do not typically provide the definitive diagnosis codes needed for accurate coding.