Injury scoring considerations
Generally injury is defined as: The anatomic lesion resulting from a transfer of energy (e.g. mechanical, chemical, thermal) rather than a complication or immediate sequalae from an injury.
All injuries require proper verification for injury coding (e.g. autopsy report, operation report, radiology report). Clinical diagnoses alone are not codeable, except in certain circumstances as defined by the coding rules and directives in the AIS 2005 - Update 2008 Dictionary.
Below are some things to consider when documenting injuries for injury coding.
List the verified injuries and their source:
- Operation Report
- Radiology
- Medical Records (medical / nursing / allied health)
Terminology:
- Preliminary diagnoses "possible" / "?" / "appears to be" / "rule out" are NOT codeable
- Rupture V's laceration
Look for specific detail of the injury:
- Size / depth
- Multiple, bilateral, co-existing injuries