Clinical Documentation Tip Sheets

-Chest pain -Myocardial ischemia -Dyspnea at rest or with minimal exertion -Other severe sign or symptom secondary to anemia

MALIGNANCY Inpatient admission is indicated for 1 or more of the following: High-risk infection, as indicated by 1 or more of the following –Hypotension (See General) –Bacteremia (if blood cultures performed) –Catheter-related infection requiring inpatient monitoring and testing –Fever with neurologic abnormalities –Skin infection Tumor lysis syndrome Gastrointestinal complications, as indicated by 1 or more of the following –Mucositis requiring IV hydration support or parenteral nutrition

–Diarrhea that cannot be managed at other than inpatient level of care (eg, frequency, risk of dehydration) –Oral candidiasis that requires inpatient management (e.g, parenteral nutrition, pain control, parenteral antifungals)

–Significant abdominal pain with suspicion of colitis Severe electrolyte abnormalities (see nephrology) Severe Pain requiring inpatient management (see general) Pathologic fracture with major instability

HEMATOLOGIC ABNORMALITIES

ANEMIA

NEUTROPENIA

> Acuity: Acute, chronic

> Acuity: Acute, chronic

> Type: blood loss, iron deficiency, anemia of chronic disease, nutritional, megaloblastic, hemolytic, sickle cell, etc. > Cause: Malignancy, GI bleed, Vitamin deficiency, drug induced

> Cause: Malignancy, drug induced, infection, etc.

> Associated conditions: e.g., neutropenic fever, neutropenic sepsis, immunodeficiency

THROMBOCYTOPENIA

PANCYTOPENIA

> Document: pancytopenia when anemia, neutropenia and thrombocytopenia are present . > Cause: drug induced; chemotherapy induced pancytopenia

> Acuity: Acute, chronic

> Cause: Liver disease, drug induced, infection, ITP, etc. > Associated conditions: bleeding, medication adjustment, i.e., holding anticoagulants