Name of the Procedure:

Common Name(s): Documentation of Burn Prior to Discharge
Technical Term(s): G8908 - Patient documented to have received a burn prior to discharge

Summary

This procedure involves the formal documentation that a patient has experienced a burn injury before being discharged from a medical facility. It ensures that the injury is recorded in the patient's medical history and helps guide further medical care as necessary.

Purpose

The documentation addresses the presence of a burn injury prior to patient discharge to ensure that appropriate follow-up care and treatments are planned. This step is critical for:

• Tracking the condition to provide appropriate continuing care.
• Informing subsequent healthcare providers.
• Ensuring proper monitoring of healing and any necessary interventions.

Indications

This documentation is specifically warranted when a patient has sustained a burn injury while under medical care. Criteria include:

• Visible burns detected by medical staff.
• Patient-reported burn injuries.
• Burns confirmed through diagnostic evaluations.

Preparation

No specific preparation is required for the documentation. However, it is essential to:

• Assess the burn thoroughly.
• Take necessary photographs or diagrams if appropriate.
• Gather detailed descriptions of the burn, including size, depth, and cause.

Procedure Description

1. Assessment: A healthcare professional examines the burn's severity and extent.
2. Documentation: The following details are recorded:
   • Location and size of the burn
   • Severity (first-degree, second-degree, etc.)
   • Time of burn occurrence
   • Potential cause or context (e.g., accidental, during a procedure)
3. Reporting: This information is incorporated into the patient's medical records and discharge summary.
4. Education: Patients are given instructions and educational materials on burn care and symptoms to watch for.

Tools and equipment used include medical record systems, measurement tools (for burn size), and possible imaging devices.

Duration

The documentation process generally takes about 15-30 minutes, depending on the burn's complexity and the detail required.

Setting

This procedure is typically performed in a hospital or outpatient clinic, either in the patient's room or a designated examination area.

Personnel

• Primary Care Physician/Nurse: Performs the initial assessment and documentation.
• Specialists (if needed): Burn specialists, dermatologists.
• Nursing Staff: Assist with documentation and patient instructions.

Risks and Complications

There are minimal risks associated with the documentation itself. Potential complications might include:

• Under-documentation: Missing critical details which could affect future care.
• Over-documentation: Including unnecessary details which may complicate the medical records.

Benefits

• Continuity of Care: Ensures that future healthcare providers are aware of the burn injury.
• Better Outcomes: Accurate documentation can lead to appropriate follow-up care, minimizing the risk of complications like infections or improper healing.
• Legal Protection: Provides a thorough record in case of medical audits or legal considerations.

Recovery

No recovery period is specifically associated with the documentation process. However, patients should be:

• Given clear instructions on burn care.
• Advised about signs of infection or complications.
• Scheduled for follow-up appointments if necessary.

Alternatives

As this is a documentation procedure, there are no direct alternatives. However:

• Verbal Reporting: While less formal, verbal reporting of the burn injury to subsequent care providers is a minimal approach.
• Photographic Documentation: Supplementing written records with photographs for clarity.

Patient Experience

Patients may experience:

• Reassurance: Knowing their injury has been appropriately documented.
• Information Overload: Receiving detailed instructions might feel overwhelming; ensure patients have contact details for follow-up questions.
• Minimal Discomfort: The physical act of documentation does not usually cause discomfort; however, the initial burn assessment might be slightly painful depending on the injury's severity.

Pain management and comfort measures should be addressed through proper burn care instructions and medications if necessary.