Clinical Documentation Tip Sheets

Hematology/Oncology

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 DISEASLEUKEMIAS AND LYMPHOMASE

NEOPLASMS

> Behavior: Malignant, benign

> Acuity: Acute, chronic

> Site: Primary and metastatic sites when applicable

> Status: in remission, not in remission, in relapse

> Type: e.g., myeloid, lymphoblastic, etc

> Associated conditions: immunodeficiency, pancytopenia, hypercoagulopathy, protein-calorie malnutrition, cachexia, weight loss, neoplasm related pain, neoplasm related fatigue/debility, oral candidiasis

COAGULATION DISORDERS

> Type : Hypocoagulopathy (Hemorrhagic Disorders): Inherited causes: hemophilia B (Factor IX deficiency), Factor XI deficiency, and fibrinogen disorders. Acquired causes: anticoagulant/antithrombotic therapy, liver disease and Vitamin K deficiency. Hypercoagulopathy (Thrombotic Disorders): Inherited causes: Factor V Leiden mutation elevated Factor VIII, and deficiencies in protein S, protein C and antithrombin. Acquired causes: malignancy, pregnancy, drugs, autoimmune disease, immobilization.

> Associated conditions: bleeding, thrombosis

Tip: If the patient is on anticoagulants document: coagulopathy due to the use of anticoagulants. Avoid supratherapeutic INR

ANEMIA Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability ( See General) Active hemolysis Active bleeding that cannot be controlled in observation care Altered mental status that is severe or persistent Recurrent syncope or near syncope Cardiac arrhythmias of immediate concern Acute peripheral ischemia (eg, cool, mottled, or cyanotic extremity) High-risk low platelet count Acute kidney injury ( See Nephrology) Clinically significant signs or symptoms that are severe or persist despite observation care as indicated by 1 or more of the following: -Heart failure