fall r/t medical event

Specialties MDS

Published

Specializes in MDS Coordinator.

A resident had a seizure, fell, lost consciousness and received a laceration to his scalp.

How would you code this in section J? His fall was related to a medical event - not a trip or loss of balance. Also, a major injury is described as a "closed head injury with alteration in consciousness". His head CT scan at the hospital was negative.

All feedback appreciated!

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