AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSED REDUCTION

question 6

Essay

AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSED REDUCTION
INDICATION: Kelli is a 15-year-old girl who fell while roller blading. She has now fractured her left thumb and will need manipulation to put it back in place. I have recommended a closed reduction and thumb spica cast application. The mother agrees with this.
PROCEDURE: Under a satisfactory level of sedation, the fracture was carefully manipulated and a well-padded and very well-molded fiberglass cast was placed over the base of the thumb. After this was applied, we applied repeat mini C-arm views and confirmed improvement in position of the fracture but still not in anatomic position.
Where it is presently, if it heals, it still will be completely functional. I reviewed this with the mother, and I have recommended that we cast this and re-manipulate it as the swelling goes down, and we will do this sometime next week.
T8.1:
SERVICE CODE(S): 26607-FA______________
ICD-10-CM DX CODE(S): S62.399A________
INCORRECT/MISSING CODE(S): ________________________________________

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Definitions:

BSFT

Brief Strategic Family Therapy, a therapeutic approach designed to address problematic behaviors and interactions within families.

Familial Distress

Emotional strain and stress that occurs within a family due to various reasons, including financial problems, illness, or conflict.

Lost Child

A family role where the individual becomes invisible and neglected as family attention often focuses on more demanding or problematic members.

Unwritten Rules

Implicit norms or expectations that are not formally documented but guide behavior within a social group or organization.