Wiki traumatic vs nontraumatic

[kmschwarz]

Patient in the ER has a CT of the head - indication is trauma, injury, pain. In the final impression, it states that the patient has a subdural hemorrhage.

Does it have to state " traumatic subdural hemorrhage", or because of the indication, can you use common sense to link the impression back to the indication?

 

[tag60]

I believe the indication of "trauma, injury" (as you noted in your post) supports a diagnosis code of traumatic subdural hemorrhage, even if the provider doesn't state that word in the final diagnosis. You are not making any assumptions if it is documented at some point in the record. (Does this answer your question, if I understood it correctly?)