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Patient Record Date of Visit: 06/19/YYYY Patient Name: Myla Milestone Date of Birth: 10/14/1998 Gender: F Patient Type: Inpatient Reason for Visit: Delivery Notes/Comments: Unit 4 Case Study 1 PREOPERATIVE DIAGNOSIS: Term intrauterine pregnancy at 39 weeks POSTOPERATIVE DIAGNOSIS: 1. Term intrauterine pregnancy at 39 weeks PROCEDURE: Vaginal delivery INDICATIONS: This is a 20-year old gravida 1 para 1 who presented at 39 weeks in active labor. She is taken to the labor and delivery suite. PROCEDURE DESCRIPTION: The patient is taken to the labor and delivery suite in active labor dilated to a 6. Her labor progressed rapidly and she was placed in the McRoberts position, the patient pushed, but without delivery of the head. The nurse then applied Suprapubic pressure and gentle traction on the baby’s head during the next major push and the baby was then delivered. The baby was bulb suctioned. The cord was then clamped, cut, and the baby was given to the awaiting pediatric staff. She delivered a viable male infant with Apgars of 8 and 9. weighing 7 pounds, 2 ounces over an intact perineum. The placenta was delivered intact with three-vessel cord. Cervix was intact. Mom and baby were taken to postpartum recovery in stable condition. What's the Pcs code

          Patient Record
Date of Visit: 06/19/YYYY
Patient Name: Myla Milestone
Date of Birth: 10/14/1998
Gender: F
Patient Type: Inpatient
Reason for Visit: Delivery
Notes/Comments: Unit 4 Case Study 1
PREOPERATIVE DIAGNOSIS: Term intrauterine pregnancy at 39 weeks
POSTOPERATIVE DIAGNOSIS: 1. Term intrauterine pregnancy at 39 weeks
PROCEDURE: Vaginal delivery
INDICATIONS: This is a 20-year old gravida 1 para 1 who presented at 39 weeks in active labor. She
is taken to the labor and delivery suite.
PROCEDURE DESCRIPTION: The patient is taken to the labor and delivery suite in active labor dilated to a 6.
Her labor progressed rapidly and she was placed in the McRoberts position, the patient pushed, but without
delivery of the head. The nurse then applied Suprapubic pressure and gentle traction on the baby’s head
during the next major push and the baby was then delivered. The baby was bulb suctioned. The cord was then
clamped, cut, and the baby was given to the awaiting pediatric staff. She delivered a viable male infant with
Apgars of 8 and 9. weighing 7 pounds, 2 ounces over an intact perineum. The placenta was delivered intact
with three-vessel cord. Cervix was intact. Mom and baby were taken to postpartum recovery in stable
condition.
What's the Pcs code

Added by Devita A.

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