Clinical Documentation Tip Sheets

SEPSIS Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability Bacteremia (if blood cultures performed) Hypoxemia (See Respiratory) Altered mental status that is severe or persistent New coagulopathy (eg, reduced platelet count consistent with disseminated intravascular coagulation)[E] Tachypnea that persists despite observation care Dehydration that is severe or persistent Inability to maintain oral hydration (eg, needs IV fluid support) that persists after observation care Evidence of end organ dysfunction that is severe or persists despite observation care Core (rectal) temperature lower than 95 degrees F (35 degrees C) Parenteral antimicrobial regimen that must be implemented on inpatient basis (e.g, infusion or monitoring needs beyond capabilities of outpatient parenteral therapy) CELLULITIS Inpatient admission is indicated for 1 or more of the following: Clinical presentation (eg, acuity of infection, rapidity of progression) or treatment regimen (eg, complex wound care, antibiotic regimen not suitable for administration at lower level of care) Bacteremia (if blood cultures performed) Limb-threatening infection Orbital infection Suspected necrotizing soft tissue infection (eg, gas in tissue). Severe oral or head and neck cellulitis (eg, Ludwig angina) Preseptal or perineal infection that is severe or progressive Hemodynamic instability (See General) Altered mental status that is severe or persistent Severe pain requiring acute inpatient management (See General) •nability to maintain oral hydration (eg, needs IV fluid support) that persists after observation care

PNEUMONIA Inpatient admission is indicated for 1 or more of the following: Hypoxemia (See Respiratory) Hemodynamic instability (See General) Altered mental status that is severe or persistent Dehydration that is severe or persistent Ventilatory assistance needed (eg, mechanical ventilation, noninvasive ventilation) Bacteremia (if blood cultures performed) Moderate-risk-category or high-risk-category patient (Pneumonia Severity Index class IV or V, or CURB-65 score of 3 or greater) Respiratory finding (e.g., Tachypnea) that persists despite observation care Complicated pleural effusions (e.g, empyema, loculated) UTI Inpatient admission is indicated for 1 or more of the following: Persistence or worsening of clinical finding (eg, fever, pain, dehydration, vomiting) despite observation care Pregnancy with suspected pyelonephritis Significant uropathy (eg, obstructive defects, moderate to severe vesicoureteral reflux) Suspected infection of an indwelling prosthetic device, stent, implant, or graft Ureteral obstruction (e.g, stone) Bladder emptying significantly impaired (eg, bladder outlet obstruction) Renal or perinephric abscess Emphysematous pyelonephritis or emphysematous cystitis Pyonephrosis Hemodynamic instability (See General) Altered mental status that is severe or persistent Severe pain requiring acute inpatient management (See General) Inability to maintain oral hydration (eg, needs IV fluid support) that persists after observation care