MDS Alert
Use Physician Query for Questionable Diagnosis
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Question: Is a subdural hematoma from a fall a traumatic brain injury? Would this constitute a major injury if it is the result of a resident falling? Indiana Subscriber Answer: A subdural hematoma is a major injury, according to the Resident Assessment Instrument (RAI) Manual’s coding guidance on falls on page J-35. The Centers for Disease Control and Prevention (CDC) says that a traumatic brain injury (TBI) “is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI may range from ‘mild,’ i.e., a brief change in mental status or consciousness to ‘severe,’ i.e., an extended period of unconsciousness or amnesia after the injury.” However, because a TBI is a diagnosis, you should query the resident’s physician to check whether the subdural hematoma constitutes a TBI, if it is not otherwise mentioned in the resident’s medical records.
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