Postoperative Complications Tip Sheet Ileus/Bowel Obstruction What is a Surgical Complication? Any deviation away from the patient’s normal postoperative course Key words to look for within the documentation to help support the diagnosis of a postoperative complication include: “Due to” “Resulted From” “Associated” “In the setting of” “Iatrogenic” According to ICD10monitor, three things must be present for the condition to be considered a complication: 1. Cause-and Effect relationship 2. Evidence of evaluation, monitoring, and treatment of condition 3. Provider must document the condition is a complication or provide further support Postoperative Complications: It's complicated. (n.d.). Retrieved June 21, 2018, from https://www.icd10monitor.com/postoperative-complications-it-s-complicated Key Points to Remember There is no timeframe on a complication Look for words such as incidental or expected versus postoperative complication Query the physician if unsure of condition/diagnosis Complications that are present on admission, are sequenced as the principle diagnosis If complication is noted, send case to the CDI Physician Advisor Physician doesn’t have to state “Complication”, as long as the condition is supported Good practice would be to have the word “Complication” stated Common Postoperative Complications Wound Dehiscence Sepsis AKI Ileus/Bowel Obstruction DVT/PE Examples: Patient admitted with abdominal pain, found to have abscess due to recent surgery of colectomy 6 days ago. Patient complaining of leg pain, DVT noted on Doppler, likely associated with recent Total Knee Arthroplasty. Patient admitted with abdominal pain, found to have bowel obstruction from recent surgery. Abscess Hematoma/ Hemorrhage