D.08 is not limited to the three listed, those are examples. I could not find the specific reference document on the ASH website either, but we’ve understood that this list is not all inclusive. The NTDB FAQ’s does tell us to report bleeding disorder for thrombocytopenia. It is for any condition where the blood does …
A question came up regarding this pre-existing condition D.08 – would this be limited to the three that are listed as examples or are there others that can be included such as thrombocytopenia or pancytopenia?
No, PTSF does not recommend capturing Functionally Dependent Health Status with documentation of a prosthetic eye as a prosthetic eye is more aesthetic than functional.
If it is documented that the patient was involved in a crash and he/she was the driver of a jeep, would you consider a jeep a car or truck? Also, if it states the MV was a SUV, what is a SUV – car or truck?
Per ICD-10 guidelines, SUV is included in the same category as pick-up truck or van. Although Jeep is not specifically defined in ICD-10, I recommend including Jeeps in the SUV/pick-up truck or van category.
In these situations, Height of Fall is recorded with an I for inappropriate. You can record any additional information you wish (excluding patient/provider specific information (PHI)) in the Cause of Injury Specify field.
Pre-existing conditions – E.00 Mental/Personality Disorder. Looking at this definition it says to refer to the NTDB definition that is consistent with APA DSM 5, 2013 – looking at this, it still isn’t really clear what to include. The following two are the ones we struggle with all the time. -Major Depressive disorder – if a doctor writes depression, is that sufficient? -Social Anxiety Disorder – if written as anxiety, is that enough?
This definition is very specific. Both the NTDS definition and PTOS definitions are consistent with the American Psychological Association (APA) DSM 5, 2013, and documentation of “depression” is not the same as the diagnosis of a major depressive disorder. The patient must have a diagnosis of a major depressive disorder OR received treatment for major …
Any previous head injury that caused anything from drowsiness to severe injury. When we say “A TBI must be clearly documented” this means any brain injury, so SDH qualifies. You do not need the actual text of “TBI”. You would often only see that wording if they don’t get a diagnosis.
Would a patient that has a refusal for blood products due to religious reasons prior to arrival and then noted on their chart stating the same be considered Advanced Directive Limited Care “written request limiting life-sustaining therapy”?
The current definition for Advanced Directive Limited Care states “the patient had a written request limiting life-sustaining therapy, or similar advanced directive, present prior to arrival at your center.” If the refusal for blood products due to religious reasons was documented in the patient’s chart prior to arrival at your center, I recommend capturing this …
We are looking for clarification regarding what is considered abuse. I understand, for example, a parent assaulting a child, a spouse/significant other assaulting a spouse, an adult child assaulting an elderly parent is abuse,, but is any physical assault considered abuse for the first registry question “was patient being evaluated for abuse?” or are there specific criteria that constitutes abuse? For example, an acquaintance or neighbor as a one-time event assaulting the patient, how would we answer that first registry question? Or a guy is sitting at a bar and someone comes up and hits him?
Please refer to the Best Practices Guidelines for abuse. If you cannot locate this resource, please contact PTSF staff, and we can provide it for you. I hope this document helps clarify abuse for you. This resource provides great information, and best practices for abstraction as well. Any physical assault is not abuse. However, according …
In situations where patients fall in place while going up steps, we recommend recording a fall height of 0 = fall on same level. This is only true if their fall did not result in a fall down the stairs. For mechanism in ICD-10, you will use the category for fall from/on stairs.
Mechanism of injury plays no role in the Pre-hospital Cardiac Arrest definition. This pre-existing condition should be considered for every PTOS patient regardless of their MOI or diagnoses.