Common CCs for Lap Appendectomy, Lap Cholecystectomy
Hello folks,
As I wrap up a presentation for general surgery, I am wondering if any of you have any suggestions for common CCs for someone with Appendicitis or Cholecystitis. For either, SIRS or even Sepsis is a possibility, Ileus is possible for many cases of Appendectomy, blood in stool is even possible. This is to show how documentation can affect the severity (I am already making the comparison of DRG 343 - uncomplicated appendectomy vs DRG 340 - Appendectomy with complicated primary diagnosis) For Cholecystectomy, hydrops of gall bladder is a distinct possibility.
Are there any other suggestions?
Thanks!
Mark
Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
http://www.sibley.org
As I wrap up a presentation for general surgery, I am wondering if any of you have any suggestions for common CCs for someone with Appendicitis or Cholecystitis. For either, SIRS or even Sepsis is a possibility, Ileus is possible for many cases of Appendectomy, blood in stool is even possible. This is to show how documentation can affect the severity (I am already making the comparison of DRG 343 - uncomplicated appendectomy vs DRG 340 - Appendectomy with complicated primary diagnosis) For Cholecystectomy, hydrops of gall bladder is a distinct possibility.
Are there any other suggestions?
Thanks!
Mark
Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org
http://www.sibley.org
Comments
acidosis, ABLA, acute kidney failure, ascites, atelectasis, cardiomyopathy, complications effecting digestive system, hemiplegia late effect CVA, diverticulitis with hemm, GI hemm, HTN kidney disease with CKD 4/ESRD, hyponatremia, ileus, malnutrition, pl effusion, portal HTN, intestinal OBST, METS to liver, METS to abd lymph nodes, UTI...
Mark, since you went to the congf...and I didn't...is this a highlight from there???
Would love to know more...