Clinical Documentation Tip Sheets

ACUTE CHOLANGITIS

Inpatient admission is indicated for ALL of the following: Systemic signs of inflammation, as indicated by 1 or more of the following: –Fever (eg, when not masked by antipyretic medication such as acetaminophen or ibuprofen) –C-reactive protein level greater than 1 mg/dL

–White blood cell count greater than 10,000/mm3 or less than 4000/mm3 Evidence of common bile duct disease, as indicated by 1 or more of the following: –Total serum bilirubin level greater than or equal to 2 mg/dL –Liver function test (ALP, GGT, AST, or ALT) greater than 1.5 times the upper limit of normal –Hepatobiliary imaging showing biliary dilation or evidence of etiology (eg, stricture, stone, previously placed stent)

ILEUS

Inpatient admission is indicated for ALL of the following: Signs and symptoms of ileus (eg, abdominal pain, distention, vomiting) that are severe (Hypotension, electrolyte abnormality, obstipation), or persistent (eg, NG tube placed and will need to be continued, IV hydration support required) Imaging study consistent with ileus

ACUTE DIVERTICULITIS

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (See General) Peritoneal signs Persistent gross bleeding per rectum resulting in drop in hematocrit Significant abnormality on imaging study, including 1 or more of the following: Fistula, Obstruction, Perforation Drainage procedure required Bacteremia (if blood cultures performed) Severe pain requiring acute inpatient management (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

LAB ABNORMALITIES

> Always: check the lab

> Document : the lab abnormality as a diagnosis and treatment, evaluation, or monitoring performed, e.g., hyponatremia Na 130 hold diuretics.