1. Postoperative Complications Tip Sheet Ileus/Bowel Obstruction
What is a Surgical Complication?
Any deviation away from the patient’s normal postoperative course
Key words to look for within the documentation to help support the diagnosis of a postoperative complication include:
“Due to”
“Resulted From”
“Associated”
“In the setting of”
“Iatrogenic”
According to ICD10monitor, three things must be present for the condition to be considered a complication:
1. Cause-and Effect relationship
2. Evidence of evaluation, monitoring, and treatment of condition
3. Provider must document the condition is a complication or provide further support
Postoperative Complications: It's complicated. (n.d.). Retrieved June 21, 2018, from
Key Points to Remember
There is no timeframe on a complication
Look for words such as incidental or expected versus postoperative complication
Query the physician if unsure of condition/diagnosis
Complications that are present on admission, are sequenced as the principle diagnosis
If complication is noted, send case to the CDI Physician Advisor
Physician doesn’t have to state “Complication”, as long as the condition is supported
Good practice would be to have the word “Complication” stated
Common Postoperative Complications
Wound Dehiscence
Sepsis
AKI
Ileus/Bowel Obstruction
DVT/PE
Examples:
Patient admitted with abdominal pain, found to have abscess due to recent surgery of colectomy 6 days ago.
Patient complaining of leg pain, DVT noted on Doppler, likely associated with recent Total Knee Arthroplasty.
Patient admitted with abdominal pain, found to have bowel obstruction from recent surgery.
Abscess
Hematoma/ Hemorrhage