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January 28, 2022

Patient comes in with a known GI bleed (so this will not be a HE). He goes for a scope to see where his bleed is and ends up getting the bleed cauterized and he also receives blood products because of this blood loss. Would you suggest picking up the scope, cauterization and admin of blood products considering none of this was done to treat or diagnosis an injury? I know the procedures (other than blood) are not required to be picked up based on the guideline book even if it were for the injury but we pick up all procedures used to treat/diagnosis injuries. Just looking for some input to see what you’d think especially with the blood products.

You are correct that you do not need to capture procedures for coexisting medical conditions. Only procedures related to evaluation and treatment of injury are required to be included in PTOS. However, if the blood products were given within first 4 hours after ED/hospital arrival, you do need to capture those volumes appropriately under the blood product data elements as there is not exclusion for medical conditions unrelated to the trauma for these data elements.

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