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Specify name of medication or drug with purpose of its use. Crohn's Disease. Document, associated complications: - Rectal bleeding. - Intestinal obstruction.
Typology: Exams
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Document specific location:
Document:
Document type:
Document cause:
Document underlying cause if known
Document any alcohol or drug use, abuse, dependence or past history
Specify name of medication or drug with purpose of its use
Document:
Document type/cause:
Document any associated:
If drug-induced:
Document, associated complications:
Document anatomical site:
Don’t use the term “inflammatory bowel disease.” Use of this term when your intended diagnosis is Crohn’s disease may understate severity of illness and risk of mortality.
Document timeframe of when complication occurred:
Document type:
Document reason for underdosing, such as:
Document phase:
- Oral
Document if sequelae of nontraumatic hemorrhage: specify type:
- Subarachnoid
Document if sequelae of:
- Cerebral infarction
Document :
Document acuity:
Document type:
- Candidal
Document any alcohol or drug use, abuse, dependence or past history
Specify name of medication or drug with purpose of its use
Document acuity:
Differentiate between:
Document type:
Document any related hemorrhage
Document any alcohol or drug use, abuse, dependence or past history
Specify name of medication or drug with purpose of its use
Document etiology:
If infectious, document organism when known or suspected
If non-infectious, document cause:
Document site and cause:
Document site and cause:
Document
- Related acute and/or chronic blood loss anemia
Differentiate between:
Document:
Document degree:
Document:
Document:
Document etiology:
Document additional signs or symptoms:
Acute Kidney Failu re:
Chronic Kidney Failu re:
Document associated underlying c ondi tion
Document dialysis status or s/p kidn ey transplant s t a tus
Document underlying cause:
Document any associated:
Document any alcohol or drug use, abuse, dependence or past history
Specify name of medication or drug with purpose of its use
Document type, such as:
Document severity:
Document BMI
Document specific sit e
Document lat erality:
Detail when a patient has presented for a specific treatment related to the n eo plas m (e.g., surgical remov al , chemotherapy, immunotherapy, ra dia tion t h er ap y)
Document mo rpholo g y:
- Malignan t
Document etiolo g y:
If morbidly obese, also document if with alveolar hypoventilation
Document BMI
Document:
Document when blood was collected:
Intraoperative/perioperative/pos t-operative (24 hr. period surrounding surgery)
Document site of administration:
Document Approach: