Amputations, Debridement and Spinal Fusion Clinical Documentation

Amputations

 

• Lower Body (include laterality)
    --Hindquarter
    --Femoral Region
    --Knee Region
    --Upper/Lower Leg
       °°High (proximal)
       °°Mid (mid portion)
       °°Low (distal)
    --Foot
       °°Complete or partial ray(s)/metatarsal(s)
    --Toe
       °°High (proximal phalanx)
       °°Mid (PIP joint or middle phalanx)
       °°Low (DIP joint or distal phalanx)
• Upper Body (include laterality)
    --Forequarter
    --Shoulder Region
    --Elbow Region
    --Upper/Lower Arm
       °°High (proximal)
       °°Mid (mid portion)
       °°Low (distal)
• Hand
    --Complete or partial ray(s)/metacarpal(s)
• Thumb/Finger
    --High (proximal phalanx)
    --Mid (PIP joint or middle phalanx)
    --Low (DIP joint or distal phalanx)

Debridement

• Depth:
    --Skin
    --Subcutaneous tissue/fascia
    --Muscle
    --Joint
    --Bone
• Type:
    --Excisional/Sharp
    --Non-excisional
• Specify the type of instrument used

Spinal Fusion

• Column fused
    --Anterior (rounded, smooth portion of spine)
    --Posterior (pedicle, lamina, facet, transverse process of spine)
• Approach
    --Anterior
    --Lateral
    --Posterolateral
    --Posterior
    --Lateral transverse
• Type of device(s) used
    --Interbody fusion device
    --Autologous bone graft
    --Nonautologous bone graft
    --Etc.
• Number of joints fused
    --L1–L3
    --L5–S1
    --Etc.