Trauma post-op vs non post-op

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This article explains the difference between post-op and non-postop trauma codes and how they are used.

If a trauma patient has an injury that is not initially treated before unit/ward arrival, code this as a non-post-op trauma admit diagnosis.

If a trauma patient has an injury that is treated before unit/ward arrival, code this as a post-op trauma admit diagnosis.

If a trauma patient is admitted to your ward/unit and is then sent to the OR for treatment and returns directly to your unit (not to RR or surgery ward), code this as a post-op trauma complication/acquired diagnosis.

If a patient acquires a trauma on the ward/unit, code this as a non-post-op trauma complication/acquired diagnosis

examples

  • Patient arrives on unit after MVA with untreated subdural hematoma
    • admitting diagnosis is Subdural Hematoma Non-Post-op MVA
  • Patient is then taken to OR for a craniotomy to evacuate a traumatic SDH from an MVA
    • the complication/acquired DX is Subdural hematoma-POST-OP - MVA