Clinical Documentation Tip Sheets

Infectious Diseases

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).

SEPSIS

Sepsis 2 > Definition: Sepsis : 2 or more SIRS criteria + infection. Severe Sepsis: Sepsis + organ dysfunction, Septic Shock: Sepsis + hypotension not responding to fluids OR lactate

> Tip: Link the infection and organ dysfunction to sepsis

Sepsis 3: > Definition : Sepsis: 2-point increase from baseline of SOFA score, Septic shock : Sepsis + hypotension requiring vasopressors AND lactate >2 > SOFA: Respiratory (P/F ratio < 400), Coagulation (Platelets < 150k), Hepatic (Bilirubin ≥ 1.2), Cardiovascular (MAP < 70),, Neurologic (GCS < 15), Renal (Creatinine ≥ 1.2)

PNEUMONIA

HIV

URINARY TRACT INFECTIONS

> Type/Organism: Aspiration, gram positive, gram negative, MRSA, MSSA, Klebsiella, pseudomonas, etc. Tip: Adding the type/organism to pneumonia may change it from simple to complex pneumonia. Tip: HAP, CAP, HCAP is not recognized as pneumonia types and code to unspecified pneumonia.

> HIV disease and AIDS code to HIV disease code. > HIV, HIV infection and HIV positive code to asymptomatic HIV code. > Document: associated HIV defining conditions, e.g., HIV disease with associated pneumocystis pneumonia

> Acuity : Acute, chronic

> Type: Pyelonephritis, cystitis, etc.

> Etiology: catheter related (CAUTI), nephrostomy tube related, ureteral stent infection, any other cause

> Organism: known or suspected

> Symptoms: Fever, pyuria, dysuria or asymptomatic bacteriuria Tip : Document POA status if UTI is due to device Tip: No code for urosepsis, document sepsis due to UTI instead

ANTIBIOTIC RESISTANCE

WOUNDS

HEPATITIS

> Type: Viral (A, B, C, D, E), alcoholic, drug induced, autoimmune

> Type: Pressure injury, Diabetic, Neuropathic, Venous stasis, Vascular >Document: location, laterality, stage and POA status

> Document: antibiotic resistance when present

> Acuity: Acute, chronic

> Associated conditions: cirrhosis, liver failure, hepatic encephalopathy, hepatorenal syndrome, esophageal varices, etc