The patient is a 23 y/o male who presents with a fracture of the femoral shaft after a wooden beam fell on him while he was working.

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. 

1. The patient is a 23 y/o male who presents with a fracture of the femoral shaft after a wooden beam fell on him while he was working. An open reduction with internal fixation (ORIF) was performed to correct the fracture using an intramedullary rod. Post-operatively on day three, the patient was pale, and labs demonstrated an RBC of <4.0. The patient is presumed to be anemic.

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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