Prematurity
Progression
- Initial versus subsequent visit
- Accurate code assignment is dependent on pregnancy
duration in weeks:
- Trimester counted from first day of last menstrual
period (LMP)
Location
Acuity
Name
- For premature infants, documentation should clarify if
patient has:
- Hyaline membrane disease
- Idiopathic respiratory distress syndrome (IRDS or RDS)
- Pulmonary hypoperfusion syndrome
Necessary Procedures
Other
- Any additional information pertinent to case
Why
- Any known causes or underlying conditions, comorbidities, associated problems,
abnormal vitals, underdosing of medications, hemorrhage, change in medications,
smoking, etc.