Principal Dx

kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
in CDI Talk Archive
91 year old male with fall in home. Sustained subdural hematoma with increasing bleed and midline shift. We have no neurologist. Recommendation for transfer, family declined. Incidental finding on CXR-Pneumonia and that became focus of treatment.

Principal subdural hematoma?

Comments

  • kerryseekircherkerryseekircher
    edited April 2016
    Yes, since that is the reason that occasioned the admission.

    Kerry Seekircher, RN, BS, CCDS, CDIP
    Clinical Documentation Program Manager
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013



  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
    edited April 2016
    Thank you Kerry

  • ssalinasssalinas
    edited April 2016
    Did this occur before or after admission to IP status? If found in ER, would the patient have been admitted if the pneumonia had not been found? I would think the subdural hematoma would be principal dx since that is what brought the patient to the ED. However if the pneumonia was discovered prior to IP admit status and patient was admitted for supportive care of the hematoma and aggressive treatment of the pneumonia, then perhaps the pneumonia....

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
    edited April 2016
    Fall brought pt in with subdural. CXR done in ER finding pneumonia. Decision to not transfer (by family) made in ER. Pt admitted.

  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
    edited April 2016
    Thank you Sharon.

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