Clinical Documentation Tip Sheets

ANTICOAGULATION I npatient admission is indicated for 1 or more of the following: Venous thromboembolism newly diagnosed

ATRIAL FIBRILLATION Inpatient admission is indicated for 1 or more of the following: Hypotension (see hypotension) Persistent symptomatic Tachycardia (eg, chest pain, dyspnea) despite observation care Acute myocardial ischemia that persists despite observation care Altered mental status that is severe or persistent Syncope with outpatient initiation or titration of medication (eg, for rate or rhythm control) not appropriate (eg, concern for bradycardia with need for telemetry monitoring beyond observation care) Heart failure (see heart failure) Suspected accessory pathway (eg, Wolff Parkinson-White syndrome) on ECG Medication toxicity (eg, digitalis) causing arrhythmia Initiation or adjustment of antiarrhythmic medication that requires cardiac monitoring (eg, telemetry) Inpatient admission is indicated for 1 or more of the following: Cardiac monitoring (eg, telemetry) appropriate, as cardiomyopathy, dilation, scar or fibrosis, disruption to normal cardiac electrical propagation, hypertrophy)​ Underlying sinus node or atrioventricular conduction disturbance (eg, tachy-brady syndrome)​ Prolonged QT interval​ Need for treatment with antiarrhythmic medication regimen that has significant proarrhythmic potential (eg, monomorphic ventricular tachycardia, torsades de pointes, bradycardia)[​ Patient without a sinus rhythm ECG to evaluate (eg, to determine QT interval, presence of accessory pathways) -Cardiac monitoring required that extends beyond observation care indicated by 1 or more of the following:​ Significant structural heart disease (eg,

or within past 3 months Underlying malignancy

Patient with mechanical cardiac valve Underlying hypercoagulable state (eg, protein C or protein S deficiency, antithrombin deficiency, antiphospholipid antibodies) Patient at temporary high risk of thromboembolism (eg, status post orthopedic surgery) Atrial fibrillation with recent stroke or transient ischemic attack (within past 3 months) New-onset atrial fibrillation in patient with history of stroke, transient ischemic attack, or other thromboembolism HTN EMERGENCY Inpatient admission is indicated for 1 or more of the following: Hypertensive emergency indicated by SBP greater than 180 mm Hg or DBP greater than 120 mm Hg with evidence of acute or worsening target organ damage, as indicated by 1 or more of the following: –Hypertensive encephalopathy –Cerebral infarction –Intracranial hemorrhage –Myocardial ischemia or infarction –Heart failure –Aortic dissection –Acute kidney injury (see Nephrology) –Papilledema/Retinal Hemmorhage