Clinical Documentation Tip Sheets

MATERNAL SOCIAL FACTORS

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HYPEREMESIS GRAVIDARUM

PRE-ECLAMPSIA

Inpatient admission is indicated for 1 or more of the following: Severe hypertension (SBP greater than or equal to 160 mm Hg or DBP greater than or equal to 110 mm Hg) Platelet count less than 100,000/mm3 (100 x109/L) Elevation of liver enzymes (eg, SGOT, SGPT) to more than twice the upper limit of normal Severe persistent right upper quadrant or epigastric pain not accounted for by alternative diagnosis Serum creatinine above baseline and greater than 1.1 mg/dL Doubling (from baseline) of serum creatinine not otherwise accounted for (eg, not due to hypovolemia) Evidence of hemolysis (e.g, lactate dehydrogenase (LDH) greater than or equal to

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability, (See General) Vomiting that is severe or persistent Dehydration that is severe or persistent Inability to maintain oral hydration (eg, needs IV fluid support) that persists despite observation care Severe electrolyte abnormalities (See Nephrology) Metabolic disorder (eg, hypochloremic alkalosis) that is severe or persists despite observation care Coagulopathy (eg, elevated PT, PTT) Ascites Acute kidney injury stage 2: 2 times baseline serum creatinine elevation Significant neurologic findings (eg, ataxia, nystagmus) Altered mental status that is severe or persistent

600 units per liter Pulmonary edema

Fetal compromise identified Hydatidiform mole identified

Cerebral or visual symptoms (eg, headache, Altered mental status, changes in vision)