Clinical Documentation Tip Sheets

PRESSURE (DECUBITUS) ULCERS

ACUTE TUBULAR NECROSIS (ATN)

MALNUTRITION

Mild and moderate(CC) Protein calorie malnutrition Severe (MCC) Protein-calorie malnutrition

Pressure ulcer stage 3 and 4 are MCCs.

ATN is MCC

DELIRIUM

ENCEPHALOPATHY

FUNCTIONAL QUADRIPLEGIA

Cause: Due to medical condition, superimposed on dementia, due to alcohol, drugs, mixed etiology, etc. (all CCs when there is cause/type).

Acuity: Acute or Chronic

Functional Quadriplegia is MCC

Type/Cause: Metabolic (MCC), Septic (MCC), Toxic (MCC), Hepatic, Uremic, Hypertensive, Hypoglycemic, etc.

CVA/ STROKE

SHOCK

Unspecified shock is CC Type/Cause: shock with type is MCC: Cardiogenic, Septic, Traumatic, Hypovolemic, Hemorrhagic, Circulatory, Distributive, etc.

CVA/Stroke is MCC Brain compression (MCC) Cerebral Edema (MCC) Aphasia, hemiparesis, neglect (CC)