sondra hayden
Networker
On the EMR emergency report the admit and chief complaint are stated as "fall". Are we allowed to abstract the specific location and type of injury from the patient statement vs nonspecific fall?
Example: Chief Complaint: Fall.
"Patient states that she tripped and fell to floor hitting her right wrist and chin. She also has right rib pain."
Example: Chief Complaint: Fall.
"Patient states that she tripped and fell to floor hitting her right wrist and chin. She also has right rib pain."