Clinical Documentation Tip Sheets

Common Inpatient CC.MCC Diagnoses 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).

METABOLIC ABNORMALITIES

CHRONIC CONDITIONS

HEART FAILURE

Acuity: Acute (MCC), Chronic (CC), or Acute on Chronic (MCC) Type: Systolic (HFrEF), Diastolic (HFpEF), or Combined.

In the H&P please list all the patient’s chronic conditions such as: COPD/ Asthma/ Chronic respiratory failure (when patient is on home O2) CHF with chronicity and type, e.g. chronic systolic CHF Obesity if BMI is 40 or above, underweight/malnutrition if BMI is 19 or less CKD with stage 1-4 (CKD 4 and 5 are CCs) or ESRD (MCC)

Document abnormal lab: Hypo/hypernatremia (CC), Acidosis (CC), Alkalosis (CC), Acute Lactic Acidosis (CC), Acute Metabolic Acidosis (CC) , etc. Tip: Acute respiratory acidosis is MCC

PNEUMONIA Type/Organism (either known or suspected): MRSA, MSSA, Klebsiella, Psuedomonas, Gram negative, Aspiration, Viral, Fungal, etc.

ARRHYTHMIA

PULMONARY EDEMA

Type: Always specify the type of cardiac arrhythmia e.g. Atrial flutter (CC), Ventricular tachycardia (CC) 3 Degree or Complete Heart Block (CC), Supraventricular Tachycardia(CC), Ventricular Fibrillation (MCC) rd Type of A-fib (3Ps): Paroxysmal, Persistent (CC), Permanent (chronic) (CC) ACUTE KIDNEY INJURY (AKI) Avoid: “Acute Renal Insufficiency” use “Acute Kidney Injury (CC), or Acute Renal Failure (CC)”

Acuity: Acute (MCC) or Chronic (CC

Pulmonary Embolism Acuity: Acute or Chronic (MCC)

All pneumonias are MCCs

ANEMIA

MALIGNANCY

Acuity: Acute or chronic

List All known or suspected primary and secondary (metastatic) sites (most are CCs).

Type: Acute blood loss Anemia (CC), iron deficiency, hemolytic, etc. Document abnormal CBC: anemia, leukopenia, thrombocytopenia or pancytopenia (CC)

Drug induced pancytopenia is MCC