April 26, 2021

Are we reading the manual correct that if a head bleed is noted on the first CT the registry is to code the size of the head bleed within the first 24 hours. If the head bleed is noted anytime after the first 24 hours that would be considered the initial confirmed diagnosis and the registrar is to capture the injury?

Correct. You are to code brain injuries based on what is documented closest to or at 24 hours, or at initial confirmed diagnosis if later than 24 hours. If a head bleed is noted after the first 24 hours, that would be considered the initial confirmed diagnosis and you would capture the injury.

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