Clinical Documentation Tip Sheets

Trauma

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

TRAUMATIC BRAIN INJURY

> Specify: the TBI e.g., traumatic subdural hematoma. TBI only codes to a non-specific code.

> Document: Loss of consciousness duration

> Document: associated neurologic deficits, e.g.. hemiparesis, quadriparesis, aphasia, dysphagia, neurologic neglect, paresthesia, hemi-sensory loss, etc. > Document: associated injuries/conditions; e.g., fractures, coma (GCS <9), encephalopathy, injury to internal organs, rhabdomyolysis, pneumothorax, hematomas, lacerations, contusions, etc. Tip: If CT/MRI shows “midline shift” or “mass effect” consider documenting brain compression. If CT/MRI shows “cerebral edema” or “brain herniation” consider adding those to your note.

COMA

> Definition: GCS score is below 9

> Document: the individual eye, verbal, and motor scores

FRACTURES

> Type: traumatic, stress, pathological, osteoporotic, etc.

> Location of the fracture

> Specify: displaced or non-displaced and closed or open

Tip: With traumatic fractures document contributing factors to the fracture if present, e.g., osteoporosis, osteomyelitis, neoplastic disease.

PNEUMOTHORAX, HEMOTHORAX

> Type: Spontaneous, Tension, Traumatic, Iatrogenic (post-operative)

Tip: post-operative and iatrogenic pneumothorax code to the same code (complication), avoid the term post operative if you only mean timeframe. Tip: document in your note pleural effusion if present in imaging reports and indicate if clinically significant (can’t be captured from imaging reports only). Pleural effusion may exclude iatrogenic pneumothorax complication if present.