Clinical Documentation Tip Sheets

GI/Hepatology

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).

LIVER DISEASE > Acuity : Acute, chronic, acute on chronic > Type: Cirrhosis, viral hepatitis, autoimmune hepatitis, hepatic steatosis, alcoholic liver disease, NASH

GI HEMORRHAGE

LIVER FAILURE > Acuity: Acute, chronic, acute on chronic > With or without coma (GCS <9) > Criteria: Acute: prolonged and progressively increasing prothrombin time: INR of > 1.5. Both Acute and chronic : AST & ALT > 3x URL and Elevated bilirubin and Low platelet count

> Type: Add the GI bleed type/cause either known or suspected

> Add: EGD/Colonoscopy findings to your note > Associated conditions: acute blood loss anemia, orthostatic hypotension (see MN Tip Card)

> Symptoms/signs: Jaundice, ascites/edema, hypoalbuminemia

> Associated conditions: e sophageal varices with or without bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, portal vein thrombosis, hepatorenal syndrome (see nephrology) , coagulopathy, protein calorie malnutrition

> Document: associated acute/chronic liver failure

INFLAMMATORY BOWEL DISEASE > Type: Crohn’s disease, Ulcerative colitis > Site: small intestine, large intestine, both > Associated conditions: abscess, fistula, bleeding, obstruction, perforation

PANCREATITIS

SHOCK LIVER (ISCHEMIC HEPATITIS) > Cause: of ischemia, e.g., heart failure (with acuity and type)

> Acuity: Acute, chronic, acute on chronic > Type/cause: gallstone, alcoholic, etc. > Associated conditions: SIRS with or without organ dysfunction and specify the organ dysfunction (see infectious diseases)

> Associated conditions: e.g., coma, hepatorenal syndrome

HIGH/LOW OSTOMY OUTPUT

DIVERTICULITIS

ISCHEMIC BOWEL DISEASE > Acuity: Acute, chronic

> Acuity: Acute

> Cause: Infection, Intestinal malabsorption/obstruction, Malnutrition, Dumping syndrome, Short bowel syndrome

> Type: Diffuse, focal

> Associated conditions: sepsis, abscess, bleeding, perforation

> Site: small intestine, large intestine

> Cause: mesenteric artery ischemia, septic shock, Crohn’s disease, etc.