# OB Delivery Documentation Guidelines



## MBass (Jun 17, 2014)

I have been researching guidelines for OB deliveries. I understand how to code Global and antepartum visits, etc. My question is what exactly needs to be documented for the delivery? We have a new system now and we are all learning the new processes but I have noticed a big change in documentation of a few deliveries. For example: Coding global vaginal delivery because patient had 4 or more visits, delivery and postpartum... but usually the delivery stated if patient had any lacerations, or if it was normal vaginal delivery and the date and time of delivery,etc. But what if documentation is now only 3 or 4 lines long. And just states briefly that it was normal or had a laceration and a viable infant ? Is that enough documentation?  I appreciate any help! Thank you.


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## bonnyr (Jun 24, 2014)

You should keep a copy of the Delivery Summary from the hospital in the patient's chart as well and it will give the main issues that were addressed.  If there were no complications, the delivery note should at least state vaginal delivery, time and baby's sex & weight.


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## leti-1977@hotmail.com (Jun 25, 2014)

*OB Delivery*

hello Everyone, 

I'm not sure how this works and how to post so please be kind! 

I'm trying to understand how normal delivery are coded; My understanding is that if the doctor does not document on the present encounter any complications the Dx should be 650 however a coworker is stating that all delivery's should have a complication code. Please help is this true or not and the correct way of doing ?? 

Thank you, 
Leticia CPC


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## shieldsa (Jun 26, 2014)

It is rare to not have a complication code, but, it can happen and 650 plus your V code for outcome of delivery would be your only two diagnosis codes.

Your coworker may be digging deep into the documentation and noticing things that others may overlook.  I have been doing OB coding for a year now and look at notes way differently now than I did before.

A few diagnosis codes that are easy to miss or forget about would be delivery before 38 weeks and delivery after 40 weeks, induced delivery, or any history diagnosis codes.  My providers are prone to list their indications at the top, but, as I read the actual note, there I find more indications.

What helped me when I first started was to slowly look through the pregnancy section of the ICD9 book to see all the different things I should be looking for.  

Hope this helps.  Good luck!


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