The Term "post-op"

Example: MD writes postop ileus on POD2 after abdominal surgery. Bowel function returns by day 4 and pt is dc'd home. Do you still query asking if the ileus is a complication because they used the word "postop". Or do you just ignore since it is inherent to surgery? I wouldn't code ileus normally in these circumstances but I'm concerned re the use of "post op"

Another example- post op atelectasis; common finding after surgery.

Post op hypotension- do you ask if its a complication?


Comments

  • The term 'post op' is a period of time. There is no linkage to a complication, therefore one would not be coded, nor queried as there is no documentation showing it required additional care, etc. See Optum360's Guide to Clinical Validation which may help you.
Sign In or Register to comment.