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November 12, 2022

The patient is a 17 y/o male presenting to the inpatient facility for the third round of chemotherapy treatment.

Indicate if the medical documentation is complete. If the documentation is considered not complete, indicate what the provider needs to complete for an accurate code to be selected.

The patient is a 17 y/o male presenting to the inpatient facility for the third round of chemotherapy treatment. The patient is immunocompromised due to the chemotherapy and began IV rehydration during the first day of treatment. The patient finishes treatment on day three and is discharged with MiraLAX for constipation, which was experienced during the admission.

Is this medical documentation complete?

If no, what documentation does the provider need to complete for an accurate code to be selected?

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