Gestational Weeks Documentation Physician Only??
I haven't been able to find this information in my searches. For coding purposes, is the physician the only provider that can document the weeks of gestation in the mom's chart?? A CDI that I work with wanted to know if gestational age documentation could be documented by a Labor and Delivery Nurse similar to GCS documentation by a nurse or EMT. Thanks for your help
Theresa Coonan BSN, RN, CDI
Theresa Coonan BSN, RN, CDI
Comments
The guidelines state based on provider documentation
Assignment of the final character for trimester should be based on the provider’s documentation of the trimester (or number of weeks) for the current admission/encounter. This applies to the assignment of trimester for pre-existing conditions as well as those that develop during or are due to the pregnancy. The provider’s documentation of the number of weeks may be used to assign the appropriate code identifying the trimester.Each category that includes trimester includes a code for unspecified trimester (see excerpt from guidelines) Unspecified trimester Each category that includes codes for trimester has a code for "unspecified trimester." The "unspecified trimester" code should rarely be used, such as when the documentation in the record is insufficient to determine the trimester and it is not possible to obtain clarification. I would only take directly from the Provider's documentation and we rarely ever see this missing in our documentation. If missing, it's usually an education issue. Thanks,JeffTheresa Coonan