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AAPC CHAPTER 13 PRACTICAL APPLICATIONS
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CASE 7
OB DELIVERY NOTE
Indications: 31 y/o G3P1 at 39 and 4/7 weeks admitted in labor. She has
been followed in the OB clinic with 12 normal antenatal visits.
Stage I: Patient was admitted with a cervical exam of 3/c/-1. She slowly
progressed to 5 cm dilation. She had SROM at 0330 which showed light
meconium. She continued to labor and reached the end of stage I at
1000 , a period of 10 hours. FHTs showed some periods of reactivity but
responded to stimulation.
Stage II: Duration of Stage II (from pushing to delivery) was approximately
3 hours. A pediatric team was present. There was slight meconium staining
,Be kind to yourself and keep practising!
, present at delivery. Presentation was OP with right shoulder anterior
shoulder. There was no nuchal cord. The cord was clamped x2 and cut and
the baby was handed to pediatric team.
Gender: Male Weight: 3772 grams. Apgars 8 /9
Stage III: Placenta delivered spontaneously with gentle traction and
fundal massage and was intact. Vagina and cervix examined for
lacerations. Inspection revealed a small second degree perineal
laceration which was repaired with 3.0 Polysorb in the usual sterile fashion
in layers. Another small lateral cutaneous tear was repaired with 3.0
polysorb and a figure-of-eight stitch. Good hemostatis was noted.
Patient will return to clinic for follow-up in 6 weeks.
What are the CPT® and ICD-10-CM codes?
58340 58300
74740-26 J7301
N97.9 Z30.430
59400
59000
O70.1
76946
O77.0
O36.0130
Z37.0
Z3A.36
Z3A.39
Correct 0
AAPC CHAPTER 13 PRACTICAL APPLICATIONS
10 missed terms
0%
Incorrect 10 Practise terms in Learn
LATEST UPDATED QUESTIONS AND ANSWERS
Practise your missed terms more until
you get them right.
10 questions & answers
Term 1 of 10
CASE 7
OB DELIVERY NOTE
Indications: 31 y/o G3P1 at 39 and 4/7 weeks admitted in labor. She has
been followed in the OB clinic with 12 normal antenatal visits.
Stage I: Patient was admitted with a cervical exam of 3/c/-1. She slowly
progressed to 5 cm dilation. She had SROM at 0330 which showed light
meconium. She continued to labor and reached the end of stage I at
1000 , a period of 10 hours. FHTs showed some periods of reactivity but
responded to stimulation.
Stage II: Duration of Stage II (from pushing to delivery) was approximately
3 hours. A pediatric team was present. There was slight meconium staining
,Be kind to yourself and keep practising!
, present at delivery. Presentation was OP with right shoulder anterior
shoulder. There was no nuchal cord. The cord was clamped x2 and cut and
the baby was handed to pediatric team.
Gender: Male Weight: 3772 grams. Apgars 8 /9
Stage III: Placenta delivered spontaneously with gentle traction and
fundal massage and was intact. Vagina and cervix examined for
lacerations. Inspection revealed a small second degree perineal
laceration which was repaired with 3.0 Polysorb in the usual sterile fashion
in layers. Another small lateral cutaneous tear was repaired with 3.0
polysorb and a figure-of-eight stitch. Good hemostatis was noted.
Patient will return to clinic for follow-up in 6 weeks.
What are the CPT® and ICD-10-CM codes?
58340 58300
74740-26 J7301
N97.9 Z30.430
59400
59000
O70.1
76946
O77.0
O36.0130
Z37.0
Z3A.36
Z3A.39
