Pathologic Fractures, Cellulitis and Gout Clinical Documentation

Pathologic Fractures

                               Pathologic Fractures

 

• Document location:
    --Bone (distal, proximal, shaft, etc.)
    --Laterality
• Document etiology:
    --Osteoporosis
       °°Disuse
       °°Drug-induced
       °°Postmenopausal
       °°Idiopathic
       °°Postsurgical malabsorption
       °°Other (specify)
    --Neoplastic disease
    --Other (specify)
• Document encounter type:
    --Initial encounter
    --Subsequent encounter
       °°Routine healing
       °°Delayed healing
       °°Nonunion
       °°Malunion
    --Sequela
• Document any associated diagnoses/conditionsx

Cellulitis

• Specify anatomic site
• Laterality:
    --Right
    --Left
    --Bilateral
• Cellulitis of “other parts of limb,” specify:
    --Right
    --Left
    --Upper
    --Lower
• Cellulitis of the “cheek,” specify:
    --Internal
    --External
• Document any associated diagnoses/conditions

Gout

• Specify the type/cause of gout:
    --Drug-induced
    --Idiopathic
    --Lead-induced
    --Primary
    --Secondary
    --Syphilitic
    --With renal impairment (specify the specific renal disease/disorder,
including acuity and/or state)
• Specify the specific joint involved along with laterality
• Specificity acuity of gout:
    --Acute
    --Chronic—With or Without Tophus
    --Gout attack
    --Gout flare
• Document any associated diagnoses/conditions