Demographic Archives

For the Gender-Affirming Therapy question, should the answer be “Non-disclosed” if the patient does not have any hormone therapy medications or if the information is not listed on facesheet’s or notes? Or can the answer be assumed to be “No”? Thank you!

If there is no hormone medication documented, enter NO. If there is hormone medication listed, and it is not document if it is gender affirming care, you are first directed to check with your physician/extender. If unable to determine, enter unknown. If the patient refuses to disclose, enter non-disclosed.

If the patient’s sex assigned at birth is Male and there is no documentation of that person identifying otherwise, would we choose Gender as “Man” or “Non-Disclosed” Or UNK since it wasn’t asked?

With no documentation for gender, use unknown. Non-disclosed is reserved for the patient actually declining to answer, meaning I would expect to see documentation that they declined to answer. I would also not assume and go with the same as sex. It is better to show that not everyone is collecting this, rather than fill …

Continue reading “If the patient’s sex assigned at birth is Male and there is no documentation of that person identifying otherwise, would we choose Gender as “Man” or “Non-Disclosed” Or UNK since it wasn’t asked?”

Can we use documentation of ‘Legal Sex’ in place of Sex Assigned at Birth?

No, legal sex may have been changed on documents from what was Sex Assigned at Birth.

We had a great discussion at our department meeting yesterday and had multiple thoughts on this MOI. Wondering if you could please offer thoughts. Pt was at a gym and fell to the floor from a stationary bike when the seat broke (sustained a R tibial plateau fracture). We tossed around multiple MOI’s including fall from one level to another; pedal cyclist injured in nontraffic accident; fall from furniture.

Great question! This would not be considered a transport accident. To capture that (pedal cyclist injured in nontraffic accident), the device assigned primarily needs to be for conveying persons or goods from one place to another. Fall from one level to another would work best in this situation.

I have a patient with ‘Daily Hookah Use’ documented throughout their chart. I have not seen this before. Should that qualify under E-cigs and vape use? Or is it not included?

Hookah is not reported. The pre-existing condition Current Smoker excludes pipe, cigar, or smokeless tobacco (including vapes or e-cigarettes). Hookah is a type of pipe.

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?

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 …

Continue reading “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?”

Would a prosthetic eye qualify for the Functionally Dependent Pre-Existing Condition?

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.

With ski/snowboard season upon up, when a patient is skiing/snowboarding and hits a tree/stationary object, would they get a fall height?

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.

Would “TBI” need to be documented in order for the previous head injury Pre-Existing condition to be picked up, or would documentation such as “SDH” be sufficient to pick this up?

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.