Good morning,
We are having some differences in opinion regarding where to find dx codes for deliveries. The example below is what is on the C-section report:
Cesarean section procedure note
Date xx/xx/xx
Surgeon - Dr. X
Assistant - Dr. Y
Preoperative diagnosis:
-SIUP at 39w 2d
Elective primary cesarean section for patient
Postoperative diagnosis:
-Same
Procedure performed
Primary low transverse cesarean section
The report then goes on to describe the anesthesia, findings, risks, and the description of the c section. There are no complications, all is well, baby is fine etc..
-Some co-workers will go in to this patients OB record or the admission note, to see if there are any other diagnosis that may apply, for example if the patient has gestational dm or htn(for example).
-Some say to just use what is on the procedure note.
Are there any documentation guidelines regarding this? I am inclined to think that we would use what is on the procedure note and that the OB's might need to be in serviced about what needs to be listed on there..
Any help in locating the guidelines is appreciated!
Happy Thanksgiving!
-Kathleen
We are having some differences in opinion regarding where to find dx codes for deliveries. The example below is what is on the C-section report:
Cesarean section procedure note
Date xx/xx/xx
Surgeon - Dr. X
Assistant - Dr. Y
Preoperative diagnosis:
-SIUP at 39w 2d
Elective primary cesarean section for patient
Postoperative diagnosis:
-Same
Procedure performed
Primary low transverse cesarean section
The report then goes on to describe the anesthesia, findings, risks, and the description of the c section. There are no complications, all is well, baby is fine etc..
-Some co-workers will go in to this patients OB record or the admission note, to see if there are any other diagnosis that may apply, for example if the patient has gestational dm or htn(for example).
-Some say to just use what is on the procedure note.
Are there any documentation guidelines regarding this? I am inclined to think that we would use what is on the procedure note and that the OB's might need to be in serviced about what needs to be listed on there..
Any help in locating the guidelines is appreciated!
Happy Thanksgiving!
-Kathleen