Admission Date: 5/6/xx , Discharge Date 5/8/xx
History : The patient is gravida 2 para 1, and was seen in my office for her prenatal visits, which were uneventful. She was admitted with a history of contractions every 3 to 5 minutes. Cervix was 100% effaced, and 9cm dilated.
Hospital course: The patient’s water broke at 2 am, after 3 hours, the patient delivered a baby girl with an Apgar score of eight at 1 minute and ten at 5 minutes. The Postpartum care given was eventful. The patient was discharged 2 days later.
Instructions to Patient: Diet as tolerated. Tylenol as needed for pain. She is to follow up in my office in 2 Weeks.
1. What is the root operation for the case?
Explanation:
In the given medical scenario, the patient was admitted with a history of contractions, and upon examination, it was found that her cervix was 100% effaced and 9cm dilated. Subsequently, her water broke, and after 3 hours, she delivered a baby girl with Apgar scores of eight at 1 minute and ten at 5 minutes. The primary purpose of the hospital admission was for the delivery of the baby.
In medical coding and classification, the root operation is a key element used in the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). The root operation defines the objective or intent of a surgical, diagnostic, or therapeutic procedure. In this case, the root operation “Delivery” accurately reflects the purpose of the patient’s hospital admission, which was to give birth to her baby girl.
The delivery root operation is used when a baby is born, regardless of the method of delivery, whether it is vaginal, cesarean section, or assisted delivery (forceps or vacuum extraction). It encompasses all procedures and actions involved in bringing the fetus out of the mother’s body during childbirth.
In summary, the root operation for this case is “Delivery” because it captures the essential purpose of the patient’s hospital admission, which was to give birth to her baby girl.
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