Perinatal Documentation
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Perinatal Documention
Progression
- When did disease process start
- Initial versus subsequent visit
Location
Acuity
Name
- Disease name, etiology, organism, severity,
degree, type
- Stage-primary, in situ, metastatic, etc.
Necessary Procedures
Other
- Conditions classified to "newborn" are those conditions
that originate in the fetal or perinatal period (before birth through first 28
days of after birth)
- Certain diagnoses originate in the perinatal period
- These diagnoses can be reported for infants over 28 days old, children and even
adults, as long as the condition originated in the perinatal period
- It is important for physicians to document that the
onset of the problem occurred during the perinatal period when that is the case
Why
- Any known causes or underlying conditions, comorbidities, associated problems, abnormal vitals, underdosing of medications,
hemorrhage, change in medications, smoking, etc.