Thrombophlebitis [Documentation Suggestions]


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.

Additional notes:



Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: 7/7/03)