Clinical Documentation Tip Sheets

UPPER GI BLEED

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability Ongoing active bleeding (eg, decreasing hematocrit) Mechanical ventilation necessary (eg, for airway protection)

Peptic ulcer with high-risk endoscopic features Variceal bleeding (eg, diagnosed on endoscopy) Anemia requiring inpatient admission, as indicated by 1 or more of the following:

–Tachycardia –Altered mental status –Heart failure –Chest pain –Dyspnea –Other findings suggesting inadequate perfusion (eg, syncope, peripheral or myocardial ischemia, end organ dysfunction) Gastric outlet or bowel obstruction Gastric or bowel perforation suspected (eg, Peritoneal signs, abdominal free air on imaging) Inability to maintain oral hydration (eg, IV fluid support needed) that persists despite observation care

LOWER GI BLEED

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (see General)

Active bleeding (eg, decreasing hematocrit) that persists despite observation care Colonoscopy findings that require continued hospitalization (eg, high risk for rebleed) Suspected or known ischemic colitis as etiology of bleeding Anemia requiring inpatient admission (See Above)

ACUTE PANCREATITIS

Inpatient admission is indicated for 1 or more of the following: Abdominal pain

Serum lipase greater than 3 times the upper limit of normal, or urinary trypsinogen-2 greater than 50 ng/mL Findings on imaging indicative of acute pancreatitis (eg, pancreatic inflammation, pancreatic necrosis, peripancreatic fluid collection)

LIVER DISEASE

Inpatient admission is indicated for 1 or more of the following: Acute liver failure in adult age 18 years or older, as indicated by ALL of the following - known chronic liver disease -Acute liver disease of less than 26 weeks' duration -INR greater than 1.5 and attributable to liver disease (eg, not due to vitamin K deficiency) -Hepatic encephalopathy of any degree Cirrhosis or chronic liver disease as indicated by ALL of the following: -Total serum bilirubin of 5 mg/dL (86 micromoles/L) or more -Elevation of prothrombin time to INR greater than 1.5 attributable to liver disease -Acute hepatic decompensation Hepatic encephalopathy Alcoholic hepatitis Hepatorenal syndrome Hepatic abscess Portal vein thrombosis Infected ascites