Clinical Documentation Tip Sheets

SPECIFICTY > Remember: acuity, type and etiology, e.g., acute on chronic HFpEFdue to hypertrophic cardiomyopathy

> Always document acuity with change from baseline

DIAGNOSTIC TERMINOLOGY

> Add: Diagnosis to each symptom and/or sign e.g., ascites due to liver cirrhosis > Use: Diagnostic terms in addition to the descriptive terms, e.g., supratherapeutic INR is not a diagnostic term, use coagulopathy in addition, with altered mental status use encephalopathy (with type) as well.

WOUND CARE AND NUTRITION NOTES > Add to your notes wound care and nutrition diagnoses, e.g., pressure ulcer of left buttock stage 3 wound care following, severe protein-calorie malnutrition agree with nutrition plan

HEMODYNAMIC INSTABILITY

Inpatient admission is indicated for 1 or more of the following: Tachycardia that persists despite appropriate treatment (eg, volume repletion, treatment of pain, treatment of underlying cause) Orthostatic hypotension that persists despite appropriate treatment (e.g., volume repletion) Hypotension as indicated by 1 or more of the following:

-Lactate of 2.0 or more secondary to hypotension -Metabolic acidosis (pH less than 7.35) -Mean arterial pressure less than 65 mm Hg -IV inotropic or vasopressor medication

SYNCOPE

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability Altered mental status that is severe or persistent

Cardiac disease or finding that indicates necessity of immediate intervention (eg, AICD placement, electrophysiologic study, surgery), treatment (eg, initiation of antiarrhythmic medication) or monitoring (eg, telemetry) beyond observation care Syncope resulting in severe injury requiring inpatient care

Recurrent syncope (eg, loss of consciousness in observation care) Severe dehydration, as indicated by 1 or more of the following: –Acute renal failure (stage 3 acute kidney injury) (See AKI in Nephrology) –Serum sodium greater than 150 mEq/L (mmol/L) Persistent dehydration as indicated by ALL of the following:

–Oral rehydration therapy not tolerated or insufficient to adequately correct dehydration –Appropriate intravenous treatment (eg, fluids) does not readily correct dehydration.

PAIN HInpatient admission is indicated for 1 or more of the following: IV opioid treatment required Pain control regimen not established in observation care Suspected new or deteriorating disease process as etiology (eg, new site of metastatic disease) requiring inpatient evaluation and treatment (e.g., urgent radiation therapy)

Palliative procedure planned that necessitates inpatient care for assessment and monitoring needs (e.g., celiac block, stent to relieve obstruction)