Encounter for examination and observation following alleged rape
ICD-10 Z04.4 is a billable code used to indicate a diagnosis of encounter for examination and observation following alleged rape.
Z04.4 is used to document encounters for examination and observation following an alleged rape. This code is critical in capturing the health status of individuals who have experienced sexual violence, which is a significant public health concern. The examination may include physical assessments, psychological evaluations, and screenings for sexually transmitted infections (STIs). Social determinants of health, such as access to care, socioeconomic status, and community support systems, play a vital role in the health outcomes of these individuals. Preventive care may involve counseling, education on STIs, and mental health support. Aftercare is essential for recovery and may include follow-up appointments, therapy, and referrals to support services. Accurate documentation is crucial to ensure appropriate care and support for survivors, as well as for public health tracking and resource allocation.
Documentation should include details of the examination, any injuries noted, psychological assessments, and referrals made.
Routine checkups following an alleged rape, screenings for STIs, and mental health evaluations.
Consideration of social determinants such as housing stability, access to mental health services, and community support.
Documentation should focus on population-level data, including incidence rates and access to care metrics.
Epidemiological studies on sexual violence and preventive health initiatives.
Tracking health outcomes and resource allocation for survivors of sexual violence.
Used when a patient presents for follow-up care after an alleged rape.
Documentation must include the reason for the visit, examination findings, and any referrals made.
Primary care providers should be aware of the need for trauma-informed care.
Documentation must include details of the alleged incident, examination findings, any injuries noted, psychological assessments, and referrals made. It is essential to capture the patient's narrative and any relevant social determinants that may impact their health.
