Discharge Summary: This 28-year-old female presented to the hospital on 4/14/XX in active labor and was...

Discharge Summary:

This 28-year-old female presented to the hospital on 4/14/XX in active labor and was admitted to the labor and delivery area.

Pregnancy History: This is the second pregnancy for this woman. She previously delivered a male infant 2 years ago. This pregnancy was normal with no complications.

What is the correct diagnostic code(s) for this case?

Hospital Course:
The patient was in labor for 9 hours and delivered a 7-pound, 12-ounce female at 1:23 a.m. on 4/15/XX. The child was examined by Dr. Peterson and referred to her care. The remaining hospital course was uneventful.

Discharge Instructions:
The patient was instructed to follow up in my office in 10 days or sooner if any concerns develop.

What is the correct diagnostic code(s) for this case?

Discharge Summary:

This 28-year-old female presented to the hospital on 4/14/XX in active labor and was admitted to the labor and delivery area.

Pregnancy History: This is the second pregnancy for this woman. She previously delivered a male infant 2 years ago. This pregnancy was normal with no complications.

What is the correct diagnostic code(s) for this case? ______________

Discharge Instructions:
The patient was instructed to follow up in my office in 10 days or sooner if any concerns develop.

What is the correct diagnostic code(s) for this case? ____________

Solutions

Expert Solution

This 28-year-old female presented to the hospital on 4/14/XX in active labor and was admitted to the labor and delivery area.

Before delivery the patient delivery codes : Gravida 2 Para 1 Live 1 Abortion 0

In simple terms we can write this as G2P1L1A0 with active labour

Gravida It is used to describe a woman who is pregnant and is also a medical term for the total number of confirmed pregnancies a woman has had, regardless of the outcome of the pregnancy
Para refers to the total number of pregnancies that a woman has carried past 20 weeks of pregnancy. This number includes both live births and pregnancy losses after 20 weeks, such as stillbirths.
Abortions refers to number of spontaneous or induced abortions
Living represents number of living children

The patient was in labor for 9 hours and delivered a 7-pound, 12-ounce female at 1:23 a.m. on 4/15/XX.

Adter delivery the patient delivery codes : Gravida 2 Para 2 Live 2 Abortion 0

In simple terms we can write this after delivery as G2P2L2A0

Nightingale answered 1 year ago

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