Case Lab · Type A · Foundation

F64

A documentation review: classification, not narrative

A clinical documentation reviewer is checking a set of case summaries for correct classification-code usage. One summary states: "Adult patient, longstanding and persistent incongruence between experienced gender and sex assigned at birth, consistent and stable over several years, seeking classification code for records purposes. No other psychiatric diagnosis noted." The reviewer's task is to identify which classification-level statement is accurate for this record, from a coding-and-documentation standpoint only.