Documentation Tip of the Week: Coma

Posted on Wed, Apr 29, 2015
Documentation Tip of the Week: Coma

When documenting coma, include the duration of time in coma (greater or less than one hour)

This is especially important in patients with a principal diagnosis of:

  • subdural hematoma
  • closed head injury
  • skull fracture
  • subdural, extradural or subarachnoid hemorrhage
  • traumatic brain injury
ICD-10 will utilize the Glasgow Coma Scale. Total score documented on presentation may be used, however, the individual scores are preferred.

The documentation of coma supports higher severity of illness and increased length of stay as well as medical necessity. Coma is not integral to the death process, and can be an additional diagnosis when a patient expires.

This documentation will support your patient being as sick on paper as they are in the bed.

 Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.


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