Clinical Documentation Tip Sheets

Critical Care

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

SHOCK

> Type: Cardiogenic, Septic, Traumatic, Hypovolemic, Hemorrhagic, Circulatory, Distributive, shock liver (see GI/Hepatology) , etc.

Tip: Remember to add the type. Without type shock codes to unspecified

CARDIAC ARREST

> Cause: Remember to add cause of cardiac arrest either known or suspected.

CRITICAL ILLNESS MYOPATHY AND POLYNEUROPATHY Definition: CIM: Flaccid weakness, often accompanied by difficulty weaning from mechanical ventilation.

CIP: Reduction in or absence of deep tendon reflexes and sensory loss.

DELIRIUM

> Acuity: acute, chronic

> Cause: Due to medical condition, superimposed on dementia, due to alcohol, drugs, ICU delirium , mixed etiology, etc.

ENCEPHALOPATHY

> Type: metabolic, septic, toxic, hepatic, uremic, hypertensive, etc.

Tip: With hepatic encephalopathy also consider documenting metabolic encephalopathy if present.

COMA

> Definition: GCS score is below 9

> Document: the individual eye, verbal, and motor scores