Docstoc

Standardized Reason for Visit Codes

Document Sample
Standardized Reason for Visit Codes Powered By Docstoc
					                    "Reason for Visit" Data Field

Coding Explanation:
Three characters comprise a unique code for each specific "Reason For Visit." The first character is used to denote the
broad category (e.g., behavior, illness, injury, etc.) for why the student is seeking nursing assistance. The second
character is used to denote the ICD-9 disease / body system category, and the third character is used to denote each
"Reason For Visit" within the categories defined by the first two characters. The third character was randomly
assigned. Combined, the three characters provide a unique code for each "Reason For Visit."




         1st Character
         Behavioral                       B
         (Physco/Social/Emotional)
         Illnesses/Sick/Disease           D
         Injuries                         I
         Needs (Economic)                 N
         Other                            O
         Prevention                       P

         2nd Character
         Congenital Conditions            A
         Hematology (Blood)               B
         Cardiovascular                   C
         Disease                          D
         Endocrine, Allergy, Immune       E
         System, Metabolic, and
         Nutritional
         Gastro-Intestinal, Dental, and   G
         Oral Conditions
         Musculoskeletal and              M
         Connective Tissue
         Nervous System                   N
         Other Conditions                 O
            Mental or Behavioral Health     P
            Conditions (Psycho-social)

            Respiratory                     R
            Skin and Subcutaneous           S
            Tissue
            Neoplasms (Tumors)              T
            Renal and Genitourinary         U
            Eye and Ear                     Y
            Not Defined                     Z

            Note ~ Codes with "strikethrough" reflect codes retired since initially proposed. Codes should not be re-used until it is varified that
            codes have not been implemented by some districts.
Codes


1   2   3 Long Description (30 char.) Short Description (15 char.) Narrative
B   P   A   Emotional                       Emotional                       Student directed need for emotional support                        21     15
B   P   B   Time Out                        Time Out                        Staff directed need for behaviorial support                        23     14
D   D   A   Fever Assessment                Fever Assess                    Taking of temperature with a thermometer.                          15     15
D   D   B   Head lice                       Head lice                       Check or re-check for headlice or nits                             19     13
                                                                            May include fever, muscle aches, headache, fatigue, sore
D D D Flu Like Symptoms                     Flu                             throat, chills cough.                                                8     8

D E A Allergy Symptoms - mild               Allergy Symptms                 Sneeezing, runny nose, cough, rash, hives, watery eyes.            10     10
                                                                            Anaphylaxis symptoms present (hives, breathing
                                                                            difficulty, swelling, flushed appearance) and emergency
D E B Allergy Symptoms - severe             Severe Allergy                  services needed.                                                     5     5

                                                                            May include blood sugar check, verify insulin pen,
D E C Diabetic Care-Scheduled               Diabetic sched                  carbohydrate counts, insulin injection or insulin pump.              8     8

                                                                             May include blood sugar check, verify insulin pen,
                                                                            carbohydrate counts, insulin injection, treatment of low
D E D Diabetic -Unscheduled Care            Diabtic unsched                 blood sugar or trouble shooting for insulin pump.                  17     15
                                                     Symptoms of low blood sugar in student without diabetes
                                                     which may include perspiration, pallor, headache,
                                                     dizziness, trembling/tingling, blurred vision, irritability,
                                                     confusion, drowsiness, poor coordination, stomachache,
D E E Hypoglycemic Symptoms        Hypoglycemia      hunger, inability to concentrate, crying.                      18    6
D G A Diarrhea                     Diarrhea          Loose, runny stools.                                            4    4
D G B Nausea and/or vomiting       Nausea/vomiting   Student reports nausea or throws up.                           13   12

D G C Stomachache/abdominal Pain Stomach/abd Pn      Discomfort or pain in stomach or abdominal area                 7    7
D M A Backache                   Backache            Discomfort or pain in back area                                 8    8
D N A Dizzy                      Dizzy               Unsteadiness, student reports lightheadedness                  13   13
                                                     Student lost consciousness or fears they will. Not related
D N B Fainting or Feeling Faint    Faint felt/did    to seizures.                                                    5    5
                                                     Discomfort or pain in the head area. Not related to head
D N C Headache (non-head injury)   Headache-no inj   injury.                                                        17   14
                                                     Possible alteration of consciousness and may include
                                                     severe uncontrolled movements of arms and legs. May
D N D Seizure Symptoms             Seizure           be observed or student reported.                               39   15
D O A Other Illness                Other Illness     Does not fit in any other stated category of illness.          29   34
                                                     May include coughing, wheezing, labored or noisy
                                                     breathing, shortness of breath, tightness of chest or
D R A Asthma Symptoms              Asthma Symptoms   student report of asthma symptoms.                             28
D R B Breathing problem            Breathing prblm   Not related to asthma, allergy or cold.                         8    8
                                                     May include runny nose, coughing, watery eyes, chest
D   R   C   Cold symptoms          Cold symptoms     congestion and possibly fever.                                  5    5
D   R   D   Cough                  Cough             Not related to asthma or cold                                  11   11
D   R   E   Sore throat            Sore throat       As reported by student.                                         7    7
D   S   A   Lump/cyst              Lump/cyste        Not related to injury.                                          9    9
D   S   B   Rash                   Rash              May include red, raised or itchy concern.                      11   11
D   U   A   Menstrual cramps       Menstrual crmps   As reported by student                                         25   14
D   Y   A   Earache                Earache           Pain or discomfort in ear area. Not related to injury.         16   12
                                                     Suspected ingestion, swallowing, inhaling, or absorbing
I   I A Poisoning                  Poisoning         of poisonous substance.                                         9    9
I   M A Back or neck injury        Back/neck inj     Any injury to back or neck.                                    17
                                                       Suspected injury to muscle, tendon or ligament;
                                                       overstretching of a muscle. May include pain, swelling or
I   M B Sprain / Strain              Sprain/Strain     discoloration of area.                                        13    4
                                                       Suspected or obvious break to bone. May include pain,
I   M C Fracture Symptoms            Sprain/Fracture   swelling or discoloration of area.                            17   15
I   N A Head injury                  Head injury       Reported or observed injury to head.                          16   15
                                                       Does not include head, neck, or back injury, bruising,
                                                       contusion, sprain, strain, or fracture. May include pain,
I   O   A   Other Injury             Other Injury      swelling or discoloration of area.                            11   11
I   R   A   Choking                  Choking           Obstruction of airway - partial or complete.                   9    9
I   S   A   Insect Sting/Bite        Bee/insect Stng   Reported or observed insect sting or bite.                    26   15
I   S   B   Bites                    Bites             Human or animal bites. Does not include insect.               17   14
I   S   C   Blisters                 Blisters          Raised pocket of blood or fluid under skin.                    7    7
I   S   D   Bruise                   Bruise            Discolored area due to injury without break in skin.          21   12

                                                       Injury caused by contact with heat, chemicals, electricity,
I   S E Burn                         Burn              radiation or friction. May include rugburn or sunburn.        13   13
                                                       Observed redness or scabbing; or may be student
I   S F Chapped Lips                 Chapped Lips      reported.                                                     12   12
                                                        Break in skin and often underlying tissue caused by
I   S G Cut or Laceration            Cut/Laceration    sharp edge.                                                   19   15
                                                       Blood flowing from nose due to injury or may be
I   S   H   Nosebleeds               Nosebleeds        spontaneous.                                                  21   14
I   S   I   Scrape or Abrasion       Scrape/Abrasion   Break in skin due to scrape on rough surface.                 11   11
I   S   J   Splinters                Splinters         Small, slender foreign fragment penetrating the skin.         16   15
I   Y   A   Nose Concern             Nose Concern      Not related to nosebleed.                                     22   15
                                                       Not related to tired, clothing, financial, food, hygiene or
N   O   A   Basic Need - Other       Basic Need        shelter.                                                      12   12
N   O   B   Tired                    Tired             Staff or student report                                       10   10
N   Z   A   Clothing                 Clothing          Clothing needed.                                              15   15
N   Z   B   Financial                Financial         Monetary assistance needed.                                   13   13
N   Z   C   Food                     Food              Food needed                                                   12   12
                                                       Hygiene needs. Not related to incontinence. May include
N   Z   D   Hygiene                  Hygiene           teethbrushing, showering etc.                                  4    4
N   Z   E   Shelter                  Shelter           Shelter need.                                                 15   15
O   C   A   Pale or Flushed          Pale or Flushed   Staff reported.                                                9    9
O   G   A   Dental or Oral Concern   Dent/Oral Cncrn   Not including hygiene                                          4    4
                                                      Unknown cause. Not a known seizure, head injury or
O N A Loss of Consciousness      Loss of Consc        fainting episode.                                              20   15
O O A Incontinence               Incontinence         Urine or Feces Accident                                        23   15
O O B Other Complaint            Other Complaint      Specify.                                                       15   15

O O C Pain                       Pain                 Pain not including stomach, head, back, ear, menstrual.        18   15
O O D Reserved                   Reserved             Student wants private conference                                9    9
                                                      Not bruise, rash, cut, abrasion, blister, chapped lips, burn
O S A Skin concern Other         Skin Cond Other      or bite.
                                                      Genital but not menstrual. May include injury, STD,
O U A Reserved                   Reserved             pregnancy.                                                     18    7
O U B Genito-Urinary Concerns    Urinary Concern      Not incontinence.                                               7    7
O Y A Ear Concern                Ear Concern          Not related to illness or earache.                             19   15
                                                      Could be injury, infection, difficulty seeing, contact
O   Y   B   Eye Concern          Eye Concern          lenses. Not related to allergy or cold symptoms.               11   11
O   Z   A   Health Counseling    Health Counsel                                                                       9    9
O   Z   B   Scheduled Visit      Scheduled Visit      Scheduled visit.                                               15
P   D   A   Immunizations        Immunizations                                                                       26   14
P   Z   A   Screening/Mandated   State Mandated       State mandated vision, hearing, scoliosis screenings.           8    8
                                                      Not mandated screenings, May include height, weight,
P Z B Screening/Non-Mandated     Non State Mandated   dental etc.                                                     5    5

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:18
posted:11/30/2011
language:English
pages:5