After an inpatient trauma admission, the tertiary survey documents an injury that was not listed on the initial ED trauma survey. What is the coder’s correct approach?
Select an answer to reveal the explanation.
Short Explanation
Trauma lists can grow after the dust settles—the tertiary survey is the cleanup pass. When a later survey finds another injury, fold it into the final coded set once the record is reconciled, not just the first ED checklist.
Full Explanation
Trauma documentation often evolves from primary and secondary surveys to tertiary findings. Final facility coding should reflect the reconciled, complete injury documentation rather than only the initial ED list. New injuries identified on tertiary survey are not automatically hospital-acquired solely because they appear later, and coding is not limited to injuries that required surgery.