tdsmitchell
Contributor
Currently I work for a hospitalist group. this group has started to admit to inpatient and discharge Elective Surgical patients.
our questions are;
can they admit and discharge an elective surgical pt, what about the global period,
what about the dx - shouldn't the dx be for comorbidities and not surgical dx,
can the dx be coded in a different order than documented or must we use the order documented by the physician even if that is not why they are seeing the pt.
I have copied in a sample admit and discharge of what we are seeing.
Your help is greatly appreciated.
ADMIT
HISTORY OF PRESENT ILLNESS: The patient is a gentleman with
prior history of an MVA , which resulted in a fracture of the
shoulder and shoulder instability. He had also had trouble with chronic
infections for which he is on suppressive therapy. The patient is here
today for elective shoulder therapy after a month of delays. He has had
trouble with nerve conduction problems but the most recent testing at
Ortho Dr office shows that he is recovering the function in his fingers.
The patient is seen in PAC-Unit today at the request of ortho Dr for
admission. The patient had surgery uneventfully. His present complains
are only throat soreness and some aching in the shoulder. He is still a
bit lethargic and has slurring of the speech. His mouth feels dry. But
otherwise he is alert, oriented and coherent. He is in no distress.
REVIEW OF SYSTEMS: Preoperatively the patient had issues with his chronic
shoulder pain and difficulty moving the shoulders. He has history of
fibromyalgia with chronic aches and pains. All other systems have been
reviewed and found to be otherwise negative.
PAST MEDICAL HISTORY:
1. MVA
2. Glaucoma in the right eye.
4. Fibromyalgia
ALLERGIES: Seasonal only known to medications.
HOME MEDICATIONS: ...
FAMILY HISTORY: His parents are alive, in good health
SOCIAL HISTORY: The patient does not smoke, drink or use any drugs.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 136/76, respirations
14, saturation 96% on room air, temperature 36.6, and heart rate 67 with
regular sinus on the telemetry.
GENERAL: The patient is a pleasant middle-aged gentleman sleepy and slurry
but appropriate and in no acute distress.
HEENT: PERRLA, EOMI, conjunctiva pink and moist.
NECK: Supple. No lymphadenopathy. Some tenderness anteriorly when
examined. No stridor.
CHEST: Clear to auscultation with good air bilaterally.
CARDIOVASCULAR EXAM: Regular rhythmic rate, S1 and S2, no murmurs and no
rubs.
ABDOMEN: Slightly air distended, soft, nontender. Normal bowel sounds.
LOWER EXTREMITIES: Without cyanosis, clubbing or edema. Left compressions.
Able to wiggle toes. Good capillary refill. No calf pain. Right shoulder
is in a sling with a bulky bandage over his shoulder. He has had surgery.
There is no blood oozing. No redness.
NEURO EXAM: Appropriate for this stage. The patient is still slightly
slurry and sleepy postop. Able to wiggle all extremities, and cranial
nerves appear intact.
LABS: Preoperative labs have been reviewed in the chart. The chemistry
shows a glucose of 112, BUN of 17, creatinine of 0.75. Remainder of the
complete chemistry panel including LFTs is normal. CBC also completely
normal with preop hemoglobin of 14.5, WBC 7.5, platelets 273.
No EKG done in this surgery.
ASSESSMENT:
1. Chronic shoulder instability with failure to multiple surgeries status
post total shoulder arthroplasty so here for elective shoulder
arthroplasty.
2. Chronic nerve damage to shoulder.
3. Prior infections to shoulder, on suppressive therapy.
4. Fibromyalgia.
5. Glaucoma.
PLAN:
1. Surgery has been performed by ortho who will be in charge of
ordering activity, diet tolerance, postoperative care, wound care, and
pain medications. Those orders have been reviewed and are in the
chart.
2. Continue with his chronic suppressive doxycycline for infection. He
also has received preoperative antibiotics.
3. Continue with his fibromyalgia medication.
4. Continue with glaucoma medications.
5. Lozenges for sore throat.
We will continue to follow up with this patient. We anticipate the patient
may have no needs prior to discharge, although this will need further
assessment when he is more awake and moving around.
DISCHARGE
DISCHARGE DIAGNOSES:
1. Right shoulder recurrent anterior subluxation.
2. Status post repair of anterior capsule, right shoulder.
3. Fibromyalgia.
4. Glaucoma.
5. Chronic methicillin-resistant Staphylococcus aureus infection of the
shoulder.
CONSULTANTS: orthopedics
HOSPITALIZATION: The patient was admitted on .... For the details of the admission please see the H P. The
patient is a very pleasant male with past medical history
of motor vehicle accident resulting in a fracture of the right
shoulder and stability. The patient had also a chronic infection in that
shoulder. He is on suppressive therapy with meds. The patient was admitted to the hospital. He had repair of the anterior capsule of the right shoulder done
He did well postop. Today he was eager to go home. He was eating well and
he was doing well overall. He went home with the following medications and
recommendations:
1. Follow up with ortho per his instructions.
2. The patient is going to continue medications as before which are...
The patient will return to the hospital if not well.
our questions are;
can they admit and discharge an elective surgical pt, what about the global period,
what about the dx - shouldn't the dx be for comorbidities and not surgical dx,
can the dx be coded in a different order than documented or must we use the order documented by the physician even if that is not why they are seeing the pt.
I have copied in a sample admit and discharge of what we are seeing.
Your help is greatly appreciated.
ADMIT
HISTORY OF PRESENT ILLNESS: The patient is a gentleman with
prior history of an MVA , which resulted in a fracture of the
shoulder and shoulder instability. He had also had trouble with chronic
infections for which he is on suppressive therapy. The patient is here
today for elective shoulder therapy after a month of delays. He has had
trouble with nerve conduction problems but the most recent testing at
Ortho Dr office shows that he is recovering the function in his fingers.
The patient is seen in PAC-Unit today at the request of ortho Dr for
admission. The patient had surgery uneventfully. His present complains
are only throat soreness and some aching in the shoulder. He is still a
bit lethargic and has slurring of the speech. His mouth feels dry. But
otherwise he is alert, oriented and coherent. He is in no distress.
REVIEW OF SYSTEMS: Preoperatively the patient had issues with his chronic
shoulder pain and difficulty moving the shoulders. He has history of
fibromyalgia with chronic aches and pains. All other systems have been
reviewed and found to be otherwise negative.
PAST MEDICAL HISTORY:
1. MVA
2. Glaucoma in the right eye.
4. Fibromyalgia
ALLERGIES: Seasonal only known to medications.
HOME MEDICATIONS: ...
FAMILY HISTORY: His parents are alive, in good health
SOCIAL HISTORY: The patient does not smoke, drink or use any drugs.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 136/76, respirations
14, saturation 96% on room air, temperature 36.6, and heart rate 67 with
regular sinus on the telemetry.
GENERAL: The patient is a pleasant middle-aged gentleman sleepy and slurry
but appropriate and in no acute distress.
HEENT: PERRLA, EOMI, conjunctiva pink and moist.
NECK: Supple. No lymphadenopathy. Some tenderness anteriorly when
examined. No stridor.
CHEST: Clear to auscultation with good air bilaterally.
CARDIOVASCULAR EXAM: Regular rhythmic rate, S1 and S2, no murmurs and no
rubs.
ABDOMEN: Slightly air distended, soft, nontender. Normal bowel sounds.
LOWER EXTREMITIES: Without cyanosis, clubbing or edema. Left compressions.
Able to wiggle toes. Good capillary refill. No calf pain. Right shoulder
is in a sling with a bulky bandage over his shoulder. He has had surgery.
There is no blood oozing. No redness.
NEURO EXAM: Appropriate for this stage. The patient is still slightly
slurry and sleepy postop. Able to wiggle all extremities, and cranial
nerves appear intact.
LABS: Preoperative labs have been reviewed in the chart. The chemistry
shows a glucose of 112, BUN of 17, creatinine of 0.75. Remainder of the
complete chemistry panel including LFTs is normal. CBC also completely
normal with preop hemoglobin of 14.5, WBC 7.5, platelets 273.
No EKG done in this surgery.
ASSESSMENT:
1. Chronic shoulder instability with failure to multiple surgeries status
post total shoulder arthroplasty so here for elective shoulder
arthroplasty.
2. Chronic nerve damage to shoulder.
3. Prior infections to shoulder, on suppressive therapy.
4. Fibromyalgia.
5. Glaucoma.
PLAN:
1. Surgery has been performed by ortho who will be in charge of
ordering activity, diet tolerance, postoperative care, wound care, and
pain medications. Those orders have been reviewed and are in the
chart.
2. Continue with his chronic suppressive doxycycline for infection. He
also has received preoperative antibiotics.
3. Continue with his fibromyalgia medication.
4. Continue with glaucoma medications.
5. Lozenges for sore throat.
We will continue to follow up with this patient. We anticipate the patient
may have no needs prior to discharge, although this will need further
assessment when he is more awake and moving around.
DISCHARGE
DISCHARGE DIAGNOSES:
1. Right shoulder recurrent anterior subluxation.
2. Status post repair of anterior capsule, right shoulder.
3. Fibromyalgia.
4. Glaucoma.
5. Chronic methicillin-resistant Staphylococcus aureus infection of the
shoulder.
CONSULTANTS: orthopedics
HOSPITALIZATION: The patient was admitted on .... For the details of the admission please see the H P. The
patient is a very pleasant male with past medical history
of motor vehicle accident resulting in a fracture of the right
shoulder and stability. The patient had also a chronic infection in that
shoulder. He is on suppressive therapy with meds. The patient was admitted to the hospital. He had repair of the anterior capsule of the right shoulder done
He did well postop. Today he was eager to go home. He was eating well and
he was doing well overall. He went home with the following medications and
recommendations:
1. Follow up with ortho per his instructions.
2. The patient is going to continue medications as before which are...
The patient will return to the hospital if not well.