Where would an outcome of delivery code (Z37--) be documented?

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The outcome of delivery code (Z37--) is specifically used in coding for the circumstances surrounding a delivery. This code is generally documented in the maternal record because it pertains directly to the mother and the outcome of her pregnancy and delivery. Including this information in the maternal record ensures that all relevant details regarding the mother's health status and the delivery's results are accurately captured for medical, administrative, and statistical purposes.

The maternal record provides important context for complications that may arise from the pregnancy or delivery and is essential for continuity of care, especially if there are subsequent pregnancies. While the neonatal record does document the details of the newborn's health and condition, the Z37 code focuses on the outcome from the mother's perspective rather than the newborn’s. Similarly, the patient's family record and general hospital record may include various types of information, but they do not specifically target the outcome of the delivery in the same way that the maternal record does. Thus, the most appropriate documentation for this code is in the maternal record.

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