Obstetric laceration
Improving Physician Documentation Specificity
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
- Document site (vaginal, labia, perineal, rectovaginal).
- If perineal,document type
| Type | Description |
|---|---|
| 1st degree | Perineal skin and subcutaneous tissue |
| 2nd degree | 1st degree and muscles |
| 3rd degree | 2nd degree and anal sphincter |
| 4th degree | 3rd degree and rectal mucosa |
- Document perineal laceration severity (1st, 2nd, 3rd, 4th).
- Document each laceration that is repaired.
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
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