Complications of Surgery
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Complications of Surgery
Progression
- Specify complication
- Link complication to procedure and clarify time frame with specific documentation of when complication occurred:
- Intraoperative
- Postoperative
Location
- Specify site
- Include laterality when appropriate
- Specify related device-catheter type, joint prosthesis, etc.
Acuity
- Acute blood loss anemia, etc.
Name
- Disease name, etiology, organism, severity, degree, type, stage, primary, in situ, or metastatic, etc.
Necessary Procedures
- Dependent upon complication
Other
- Encounter type-initial, subsequent, sequela
Why
- If related to anesthesia or other medication
- Name medication and corresponding manifestation