Record and code all procedures undertaken during the episode of admitted patient care in accordance with the Australian Coding Standards (refer to ACS 0016 General procedure guidelines, ACS 0042 Procedures normally not coded, ACS 0029 Coding of contracted procedures, ACS 0049 Disease codes that must never be assigned). Procedures are derived from and must be substantiated by clinical documentation.
It is possible to have duplicate codes in this section, for example, bilateral cataract extraction requires two codes to represent the bilateral aspect of the procedure. Please refer to ACS 0020 Bilateral/Multiple Procedures for further information.
All significant procedures undertaken from the time of admission to the time of separation should be coded. Procedures performed in the hospital emergency department, or elsewhere, that precede the admission time should not be coded in the admitted patient episode. Significant procedures include diagnostic and therapeutic procedures. Also include any procedures that were performed under contract with another contracted hospital, health authority or private health provider (non-hospital) and use the contract flag to identify whether they were performed on an admitted or non-admitted basis.
Queensland Hospital Admitted Patient Data Collection (QHAPDC):
Punctuation is excluded in QHAPDC.