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Diagnosis Documentation Requirements
Abdominal Pain
Document specific location:
- RUQ - RLQ
- RLQ - LLQ
- Periumbilic
- Epigastric
- Generalized
Document:
- Acute abdominal pain
- Abdominal tenderness
- Rebound abdominal pain
Anemia
Document type:
- Nutritional deficiency (iron, Vit B12, folate, protein, etc.)
- Hemolytic (enzyme disorder, thalassemia, etc.)
- Sickle cell (with or without crisis) with acute chest syndrome or splenic sequestration
- Aplastic (drug induced, idiopathic, etc.)
- Blood loss (acute, chronic, postoperative)
Document cause:
- Neoplastic disease
- Chronic kidney disease
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
Barrett's Esophagus
Document:
- With low grade dysplasia
- With high grade dysplasia
- Without dysplasia
Colitis
Document type/cause:
- Clostridium difficile
- Drug-Induced
- Due to radiation
- Infectious
- Ischemic (acute, subacute, or chronic)
- Pseudomembranous
- Ulcerative
- Crohn's disease
Document any associated:
- Bleeding
- Abscess
- Fistula
- Obstruction
If drug-induced:
- Specify name of medication or drug with purpose of its use
Crohn’s Disease
Document, associated complications:
- Rectal bleeding
- Intestinal obstruction
- Fistula
- Abscess
Document anatomical site:
- Large intestine
- Small intestine
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.
Complications of
Surgery
Document timeframe of when complication occurred:
- Intraoperatively
- Postoperatively
Drug Underdosing
Document type:
- Intentional versus
- Unintentional
Document reason for underdosing, such as:
- Financial hardship or
- Age related dementia
Dysphagia
Document phase:
- Oral
- Oropharyngeal
- Pharyngeal
- Pharyngo-esophageal
Document if sequelae of nontraumatic hemorrhage: specify type:
- Subarachnoid
- Intracerebral
- Intracranial
Document if sequelae of:
- Cerebral infarction
Esophageal
Reflux
Document :
- With or without esophagitis
Esophagitis
Document acuity:
Document type:
- Candidal
- Due to gerd/reflux
- Eosinophilic
- Tuberculous
- Ulcerative (specify w/bleeding)
Document any alcohol or drug use, abuse, dependence or past history
Specify name of medication or drug with purpose of its use
Diagnosis Documentation Requirements
Gastritis
Document acuity:
Differentiate between:
- Gastritis
- Gastroduodenitis
- Duodenitis
Document type:
- Alcoholic
- Superficial
- Atrophic
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
Gastroenteritis
Document etiology:
- Infectious
- Non-infectious
If infectious, document organism when known or suspected
If non-infectious, document cause:
- Radiation or drug induced, specify drug when known
- Allergic or food hypersensitivity, specify food when known
Gastrointestinal
Hemorrhage
Document site and cause:
- Angiodysplasia (specify site) with hemorrhage
- Crohn's Disease with rectal bleed
- Diverticulitis (specify site) with bleed
- Duodenal ulcer with hemorrhage
- Duodenitis with bleed
Document site and cause:
- Esophageal ulcer with bleed
- Esophageal varices with bleed
- Gastric ulcer with hemorrhage
- Gastritis (specify type) with bleed
- Gastroduodenitis with bleed
- Ulcerative Colitis (specify type) with bleed
Document
- Related acute and/or chronic blood loss anemia
Differentiate between:
- Hematemesis
- Melena
- Rectal Bleed
Hemorrhoids
Document:
Document degree:
- First degree
- Second degree
- Third degree
- Fourth degree
Document:
- Residual hemorrhoidal skin tags
- Perianal venous thrombosis
Hepatic Failure/
Hepatic
Encephalopathy
Document:
- Acute/subacute Or
- Chronic, if with hepatic coma
Document etiology:
Document additional signs or symptoms:
- Confusion
- Altered levels of consciousness
- coma
Kidney Failure
Acute Kidney Failu re:
- Tubular n ecr osis
- Acute cortical n ecr osis
- Medullary necr osis
Chronic Kidney Failu re:
- Specify stage as 1 through 5
- Specify if en d-s t a ge
Document associated underlying c ondi tion
Document dialysis status or s/p kidn ey transplant s t a tus
Liver Cirrhosis
Document underlying cause:
- Alcoholic
- Fatty
- Syphilitic
- Congenital
- Cryptogenic
Document any associated:
- Ascites
- Fibrosis
- Sclerosis
- Portal Hypertension
- Esophageal Varices (w/or wo/ bleed)
- Viral Hepatitis
Document any alcohol or drug use, abuse, dependence or past history
Specify name of medication or drug with purpose of its use
Malnutrition
Document type, such as:
- Protein calorie
- Protein energy
Document severity:
- Mild or 1st^ degree
- Moderate or 2nd^ degree
- Severe or 3rd^ degree
Document BMI
Neoplasms
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
- Ben ign
- In si tu
- Uncertain b eh a v i or
- Unspecified b eh a v i or
Obesity
Document etiolo g y:
- Due to excess calories or nu tr i tional
- Due to d r u gs
- Other, for example, due to thyroid or pituitary dis or d er
If morbidly obese, also document if with alveolar hypoventilation
Document BMI
Diagnosis Documentation Requirements
Transfusion
Document:
- Substance transfused: (FFP, RBC, albumin, etc.)
- Autologous or nonautologous
Document when blood was collected:
Intraoperative/perioperative/pos t-operative (24 hr. period surrounding surgery)
- Previously collected
- Salvage (24 hr. period surrounding surgery)
Document site of administration:
- Central artery or vein
- Peripheral artery or vein
Document Approach:
