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Inpatient Medical Surgical Cases
M/S DRG NAME
470
Major Joint Replacement or Reattachment of Lower
775
Vaginal Delivery without Complicating Diagnoses
795
Normal Newborn
765
Cesarean Section with
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How to fill out inpatient medical surgical cases

How to fill out inpatient medical surgical cases
01
Start by collecting all necessary patient information, such as demographics, medical history, and insurance details.
02
Create a new inpatient medical surgical case record in the hospital's electronic health record (EHR) system.
03
Enter the patient's personal information, including name, age, gender, and contact details.
04
Document the patient's medical history, including any past surgeries, medical conditions, and allergies.
05
Specify the reason for admission and the surgical procedure planned.
06
Enter relevant vital signs, laboratory results, and radiology reports.
07
Include any additional tests or consultations required before the surgery.
08
Document the patient's insurance information and obtain necessary authorizations.
09
Ensure all necessary pre-operative assessments and clearances are completed.
10
Communicate with the surgical team and anesthesia providers to coordinate the patient's care.
11
Once the surgery is completed, document the details of the procedure and any complications encountered.
12
Regularly update the patient's progress, including post-operative assessments, medication administration, and nursing care.
13
Collaborate with other healthcare professionals involved in the patient's care, such as physical therapists and social workers.
14
Ensure accurate and timely billing for the inpatient medical surgical case.
15
Review and verify all entered information before finalizing the patient's record.
Who needs inpatient medical surgical cases?
01
Inpatient medical surgical cases are needed by patients who require surgical intervention that cannot be performed in an outpatient setting.
02
These cases encompass a wide range of surgical procedures, such as major organ surgeries, orthopedic surgeries, cancer surgeries, and complex procedures.
03
Patients with acute medical conditions or those who need post-operative intensive care may also be candidates for inpatient medical surgical cases.
04
In some cases, the decision for inpatient admission might depend on the patient's insurance coverage or hospital policies.
05
Ultimately, the healthcare provider, in consultation with the patient, determines the need for an inpatient medical surgical case.
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What is inpatient medical surgical cases?
Inpatient medical surgical cases refer to cases where a patient is admitted to a hospital for a surgical procedure and requires inpatient care.
Who is required to file inpatient medical surgical cases?
Healthcare providers, hospitals, and medical facilities are required to file inpatient medical surgical cases.
How to fill out inpatient medical surgical cases?
Inpatient medical surgical cases can be filled out by documenting the patient's information, surgical procedure details, and post-operative care provided.
What is the purpose of inpatient medical surgical cases?
The purpose of inpatient medical surgical cases is to track and monitor patient outcomes, assess the quality of care provided, and facilitate reimbursement for healthcare services.
What information must be reported on inpatient medical surgical cases?
Information such as patient demographics, surgical procedure details, anesthesia used, and post-operative complications must be reported on inpatient medical surgical cases.
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