Thrombophlebitis Documentation Suggestions
- List any history of recent surgery or immobility.
- Describe clinical signs and symptoms (e.g., hard indurate area, erythema, Homan’s sign, pulling sensation in calf, etc.).
- Document work-up (e.g., duplex ultrasound, contrast venogram, MRI, RBC agglutination assay, etc.).
- Document treatment (e.g., anticoagulant, urokinase, compression stockings, etc.).
- Specify which vein was affected and whether this vein would be considered deep or superficial.
|Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: http://www.hce.org/medicare/mcareHPMP.html 7/7/03) |