Documentation and Coding for Patient Safety Indicators
12 Deep Vein Thrombosis (DVT) Inadequate documentation, such as “rule out” DVT or pulmonary embolism, without alternative diagnosis established after study, can lead to inaccurate coding (Romano, 2010). 13 Postoperative Sepsis Cannot code as postoperative sepsis if documentation does not indicate whether infection actually occurred, such as ... ................
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