Fractures, Burns and Underdosing Clinical Documentation

Fractures

Fractures

 

• Cause:
    --Traumatic
    --Stress
    --Pathologic
• Location:
    --Which bone?
    --Which part of the bone?
    --Laterality (right, left, or bilateral)
• Type:
    --Non-displaced
    --Displaced
    --Open (Gustilo classification where applicable)
    --Closed (Greenstick, spiral, etc.)
    --Salter-Harris (specify type)
• Encounter:
    --Initial
    --Subsequent
       °°For routine healing
       °°For delayed healing
       °°For non-union
       °°For malunion
    --Sequela (such as bone shortening)
• Include the external cause of the fracture, such as fall while skiing, motor
vehicle accident, tackle in sports, etc.
• Document any associated diagnoses/conditions

Burns

• Type:
    --Corrosion
    --Thermal
• Site:
    --Specify body part
    --Include laterality
• Degree:
    --First
    --Second
    --Third
• Document total body surface area (TBSA) burned (percentage)
• Specify the percentage of third degree burns
• Include the external cause of the burn, such as house fire, stove, acid, etc.
• Document any associated diagnoses/conditions

Underdosing

• Using a prescribed medication less frequently than prescribed, in small
doses, or not using the medication as instructed should be documented
as “underdosing” by the provider
• If the reduction in the prescribed dose of the medication results in a
relapse or an exacerbation of the medical condition for which the drug is
prescribed, the medical condition must also be documented