Debridement
I need a second opinion.
Op note looks like this:
The wound was explored. This wound
basically went down onto the lateral distal wall of the calcaneal tuberosity. The surrounding
tissues were somewhat chronic appearing with poorly vascularized tissue. Sharp debridement of
the peripheral wound took down the edges to healthier appearing tissue and fat. The wound was
extended proximally so that I could access the lateral wall of the calcaneal tuberosity more
freely. Retractors were placed and I explored the lateral calcaneus. I did not find any signs
of bone lysis or pockets of necrotic or infected bone. His cortex was intact surrounding this
whole area and into the plantar lateral calcaneal tuberosity. I did use a rongeur to resect a
small amount of bone in the area contiguous with his previous wound. The bone was sent as a
deep culture and some soft tissue resected from the peripheral wound was sent for superficial
tissue culture. The wound was then irrigated with pulse lavage, using 3 liters of sterile
saline. The wound VAC was then placed on the lateral wound.
In your opinion does this describe an irrigation and debridement or an excisional debridement (I realize the MD has to say excisional)? Something else?
Thanks!
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
Op note looks like this:
The wound was explored. This wound
basically went down onto the lateral distal wall of the calcaneal tuberosity. The surrounding
tissues were somewhat chronic appearing with poorly vascularized tissue. Sharp debridement of
the peripheral wound took down the edges to healthier appearing tissue and fat. The wound was
extended proximally so that I could access the lateral wall of the calcaneal tuberosity more
freely. Retractors were placed and I explored the lateral calcaneus. I did not find any signs
of bone lysis or pockets of necrotic or infected bone. His cortex was intact surrounding this
whole area and into the plantar lateral calcaneal tuberosity. I did use a rongeur to resect a
small amount of bone in the area contiguous with his previous wound. The bone was sent as a
deep culture and some soft tissue resected from the peripheral wound was sent for superficial
tissue culture. The wound was then irrigated with pulse lavage, using 3 liters of sterile
saline. The wound VAC was then placed on the lateral wound.
In your opinion does this describe an irrigation and debridement or an excisional debridement (I realize the MD has to say excisional)? Something else?
Thanks!
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