Clinical Documentation Tip Sheets

Cardiovascular

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).

HEART FAILURE

CARDIOMYOPATHY

PULMONARY EDEMA

> Acuity: Acute, Chronic, or Acute on Chronic > Type: Systolic (HFrEF), Diastolic (HFpEF), or Combined. Tip: Remember to add the type. Without type CHF codes to unspecified

> Acuity: Acute or Chronic

> Type: Ischemic, hypertrophic, dilated, restrictive. Tip: Remember to add associated heart failure with acuity and type.

> Type: cardiogenic, or non cardiogenic

Tip: Remember to add acuity. Without acuity pulmonary edema defaults to chronic.

COR PULMONALE

SHOCK > Type: Cardiogenic, Septic, Traumatic, Hypovolemic, Hemorrhagic, Circulatory, Distributive, shock liver (see GI/Hepatology), etc. Tip: Remember to add the type. Without type shock codes to unspecified

CARDIAC ARREST > Cause: Remember to add cause of cardiac arrest either known or suspected.

> Acuity: Acute or chronic

> Link to pulmonary embolism when appropriate

OTHER CARDIAC ARRHYTHMIAS

MYOCARDIAL INJURY > Myocardial infarction Type 1: Identification of a coronary thrombus by angiography or autopsy. Troponin elevation (delta) with one ore more of symptoms, EKG changes, echo changes. > Myocardial infarction Type 2: Imbalance between myocardial oxygen supply and demand unrelated to acute atherothrombosis. Troponin elevation (delta) with one ore more of symptoms, EKG changes, echo changes. > Non-ischemic myocardial injury: Troponin elevation without evidence of ischemia (acute for delta and chronic for no delta).

ATRIAL FIBRILLATION

> Paroxysmal: Terminates spontaneously or w/ intervention within 7days of onset > (Other) Persistent: Continuous sustained >7 days > Long-standing persistent (CC): Continuous >12 months > Permanent (CC): Decision to stop attempts to restore and/or maintain sinus rhythm Tip: “Chronic atrial fibrillation” may result in payment denial for Watchman procedures

> Type: Document type of arrhythmia

> Add: EKG findings to your notes and the clinical significance of the findings

> Demand ischemia: Symptoms/EKG changes without troponin elevation.