Clinical Documentation Tip Sheets

RHABDOMYOLYSIS

> Type: traumatic, non traumatic: metabolic, inflammatory, ischemic

> Document: associated AKI, ATN, electrolyte imbalance

WOUNDS

> Type: Traumatic, pressure injury, Diabetic, Neuropathic, Venous stasis, Vascular

> Document: location, laterality, stage and POA status

DEBRIDEMENT

> Type: excisional or non-excisional

> Deepest level of debridement: skin, subcutaneous tissue, muscle, or bone

> Tissue removed: necrotic, devitalized, viable, or non-viable

> Avoid: I&D spell it out ; incision and drainage , or incision and debridement

TRAUMATIC BRAIN INJURY

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability Altered mental status that is severe or persistent Glasgow coma scale score of less than 13 GCS Calculator Worsening of neurologic function post presentation New signs or symptoms (eg, dizziness, vomiting, headache) that are severe, or persist despite observation care New focal signs on neurologic examination Evidence of increased intracranial pressure (ICP) New (or presumed new) intracranial pathology on imaging (eg, CT scan) that requires intervention or monitoring beyond observation care CSF leak Recurrent seizures Significant respiratory (eg, neurogenic pulmonary edema) or cardiac (eg, arrhythmia) abnormalities secondary to brain injury

RIB FRACTURES

I npatient admission is indicated for 1 or more of the following: Hemodynamic instability Flail chest