Wiki Delivery documentation


Bay City, MI
Best answers

I would like guideness on the delivery record/report. I work at a residentency program.

The residents documents and a teaching physician must document also.

Is a delivery considered a major or minor procedure?

Medicare's guidelines state that OB procedures follow surgery documentation requirements. With that being said, a major procedure the op report is sufficient with no additional documentation from the teaching physician.

Minor procedures require the teaching physician to be present for the critical portions of the procedure and to document as such.

Major procedures are defined as procedures with global days.

Minor procedures are defined as procedures with no global or 10 day global procedures.

Deliveries vaginal or C-section have no global days.

Am I interpreting this correctly?

Lynn Wilks :(
That is very interesting...

I would still rather think of delivery as a major procedure, even though it does not have the same global days as a hysterectomy, for example, most delivery codes themselves are global and include antepartum + postpartum care. Even if your doctor only performs the delivery, there is still a six-week postpartum (global) period for care afterward.

Just my two cents; I've never thought about it from that persepctive before! :)