Post op /surgical site infection

vanessa.falkoffvanessa.falkoff
in CDI Talk Archive
Hi all,
Does anyone have any advice or a query they can share for when a patient comes in 2 months post op breast surgery with cellulitis or BKA with osteomyelitis?
Doesn't the physician need to document a link?

Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    I did infection control nursing at one point in my career and I would be hard pressed to count an infection presenting 2 months postoperative as a complication. Most postoperative infections occur within a week or less. You would have to have documentation as to when the symptoms presented and how it was treated in order to directly link those as post-operative complication. At least that's my opinion.



    Robert



    Robert S. Hodges, BSN, MSN, RN, CCDS

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



    VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)

    VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated



    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

    3
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    For suspected complications we use the attached query

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
    923
  • rmhosler1rmhosler1
    edited May 2016
    I just watched a program on coding postop complications and it said that
    a complication is a complication if the physician documents it as such.
    I can see both sides of this situation.

    We don't consider time a factor. We always ask for the link regardless.






    Mary A. Hosler, MSN RN
    Alumnus CCRN
    McLaren Bay Region
    1900 Columbus Ave.
    Bay City, Michigan 48708
    (989) 891-8072
    mary.hosler@mclaren.org

  • robert.hodges2robert.hodges2
    edited May 2016
    Here is a link on JustCoding.com on when to query for postoperative
    complications.

    http://www.justcoding.com/269715/recognize-when-to-query-for-postoperati
    ve-complications

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



    VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
    ("I CARE")

    VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
    Agile, Integrated



    "We are dealing with Veterans, not procedures; With their problems, not
    ours." --General Omar Bradley

  • vanessa.falkoffvanessa.falkoff
    edited May 2016
    Thank you Katy!
    v
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Thank you Robert and Katy!

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603

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