R10.11 - Right upper quadrant pain

Clinical Definition

A bacterial infection located on the outer layer or surface of an organ or tissue, as opposed to penetrating deeply into tissue. Common examples include superficial skin infections, minor wound infections, or surface-level mucosal infections.

Documentation Requirements

• Anatomical location of the infection (specific site)

• Confirmation that infection is superficial/surface-level only

• Causative organism if identified (e.g., staph, strep)

• Signs and symptoms observed

• Acuity (acute vs chronic)

• Treatment plan

• Any contributing factors (e.g., wound, abrasion)

Common Synonyms

• Surface infection

• Topical infection

• Skin infection

• Minor wound infection

• Surface bacterial growth

Coding Conflicts

Excludes1:

• Deep tissue infections

• Systemic infections

• Internal organ infections

Excludes2:

• Fungal infections

• Viral infections

• Parasitic infections

Scribing.io Automation

The AI scribe automatically identifies key terms indicating superficial bacterial infections such as:

• Location descriptors ("surface," "superficial," "topical")

• Bacterial terminology

• Surface-specific symptoms (redness, warmth, minor swelling)

• Treatment notes involving topical antibiotics
  The system distinguishes these from deep tissue infections based on contextual clues and specific terminology.