Multiple Significant Trauma - ACDIS多个重大创伤酸.ppt

* MDC 24 Objectives ? Gain a practical understanding of principles governing Multiple Significant Trauma under the MS-DRG system Recognize clinical clues, signs and symptoms of specific disease entities subject to unrecognized opportunities for clinical clarification during the chart review process Learn how to practically apply underlying principles of Multiple Significant Trauma through use of case studies as part of the presentation Presented by; Kathy Thomas, RN Clinical Documentation Specialist, Wheaton Franciscan Health Care – Elmbrook Memorial Renee Hedtcke, RN, CCDS, Aurora Medical Center Summit MST Surgical DRG 955 Craniotomy RW 5.4529 ALOS 11.7 956 Limb Reattachment, RW 3.6322 ALOS 8.5 hip or femur procedure 957 Other OR procedures w/ MCC RW 6.6017 ALOS 14.5 958 w/CC RW 3.7491 ALOS 9.2 959 w/o CC/MCC RW 2.4711 ALOS 5.7 DEFINITION OF TRAUMA? Refers to wound body wound/shock produced by sudden physical injury from accident or violencemajor trauma. This can result in secondary complications; ? shock/failure/death. Treatment of the trauma patient often involves multiple ?management diagnostics and procedures What Qualifies for MST PDX from Trauma Diagnosis List AND 2 additional body sites _____________ OR ____________ ? PDX from 1 body site 1 additional body site Trauma Diagnosis List Less severe and do not qualify as a “body site” ? Examples: Closed or open skull fractures with no or unspecified LOC, or w/ concussion Concussion w/ no LOC, unspecified, or LOC 1 hr Vertebral fracture, open or closed, without spinal cord injury