Record and code all procedures undertaken during the episode of care in accordance with the Australian Coding Standards (refer to ACS 0010 General abstraction guidelines, ACS 0016 General procedure guidelines, ACS 0042 Procedures normally not coded, ACS 0029 Coding of contracted procedures). Procedures are abstracted 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.
Admitted patient care:
Procedures performed in the hospital emergency department, or elsewhere, that precede the admission time should not be coded in the admitted patient episode. 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.