Clinical Documentation Tip Sheets

DOCUMENTATION FOLLOWING SURGERY

> Document: diagnoses that occurred after the surgery to the most specificity possible (see other specialties Tip cards) > Avoid “post-operative” to indicate timeframe. May result in the coding of a surgical complication. Expected surgical outcomes should not be documented as “post-op” > Examples: “POD 2 mechanical ventilation protocol s/p CABG” “Expected ileus s/p abdominal surgery” “Post op course included acute blood loss anemia and delirium on POD 3”

SURGICAL COMPLICATIONS

> See PSI Tip Card.

ACUTE CHOLECYSTITIS

Inpatient admission is indicated for ALL of the following: Right upper quadrant pain, mass, or tenderness Systemic signs of inflammation, as indicated by 1 or more of the following: –Fever –C-reactive protein level greater than 1 mg/dL –White blood cell count greater than 10,000/mm3 or less than 4000/mm3 Imaging findings consistent with or indicative of acute cholecystitis Cholecystectomy not anticipated (ie, not during current hospital stay) and treatment will be medical (ie, intravenous antibiotics)

CALCULUS OR OBSTRUCTION OF GALLBLADDER OR BILE DUCT

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (See General) Common bile duct obstruction diagnosed (eg, by imaging) Cholecystoenteric fistula Vomiting that is severe or persistent Dehydration that is severe or persistent Severe pain requiring inpatient management (See General) Bacteremia (if blood cultures performed)

SMALL BOWEL OBSTRUCTION

Inpatient admission is indicated for ALL of the following: Signs and symptoms of bowel obstruction (eg, vomiting, inability to tolerate PO intake, pain, distention) that are severe (feculent vomiting, Hypotension, electrolyte abnormality, evidence of bowel ischemia or suspected perforation), or persistent (eg, NG tube placed and will need to be continued, IV hydration support required) Imaging study consistent with bowel obstruction