Clinical Documentation Tip Sheets

Patient Safety Indicators 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).

PSI-3 HOSPITAL ACQUIRED PRESSURE ULCERS:

Inclusions: Pressure ulcers stage 3, 4 and unstageable not present on admission.

Exclusions: Stage 1 and 2 pressure ulcers. Exfoliative Skin Disorders.

Tip: Always document the POA status of the pressure ulcers

PSI-6 IATROGENIC PNEUMOTHORAX:

Inclusions: Iatrogenic pneumothorax not present on admission. Post-procedural pneumothorax not present on admission.

Exclusions: Pleural Effusion. Other etiologies of pneumothorax, e.g., traumatic, spontaneous, tension.

Tip: Document pleural effusion if clinically significant

Tip: If not a complication, avoid the term post-operative or post-procedural.

PSI- 9 PERIOPERATIVE HEMORRHAGE OR HEMATOMA:

Inclusions: Post-operative hemorrhage or post-operative hematoma, and Control of bleeding/drainage of hematoma procedure.

Exclusions: Coagulation Disorders. Thrombocytopenia.

Tip: Document Coagulopathy due to anticoagulants if the patient is on anticoagulants.

Tip : Document abnormal lab findings, e.g.. thrombocytopenia for low platelets and coagulopathy for abnormal coagulation profile.

PSI-10 POST-OP ACUTE RENAL FAILURE REQUIRING DIALYSIS:

Inclusions: Post-op acute renal failure or acute kidney injury following “ELECTIVE” admission, and Any ICD-10 procedure code for dialysis.

Exclusions: Cardiac arrest, Shock and Arrhythmia POA. Chronic Kidney Disease stage 5 and ESRD.

Tip: Document if the patient has CKD with stage .

Tip: Document if the patient has cardiac arrhythmia on admission.