Diabetes, Coagulopathy and Purpura Clinical Documentation

Diabetes

Main Symptoms Of Diabetes

 

• Type:
    --Type 1
    --Type 2
    --Drug/chemical induced
    --Due to underlying condition
    --Other specified type
• Control:
    --Inadequate control
    --Out of control
    --Poorly Controlled
    --Hypoglycemia
    --Hyperglycemia
• Insulin use
• Document any associated diagnoses/conditions
• Manifestation/Complication (document link to diabetes)
    --Circulatory complications
    --Hyperosmolarity
    --With or without coma
    --Hypoglycemia
    --Ketoacidosis
    --With or without coma
    --Kidney complications
    --Neurological complications
    --Ophthalmic complications
    --Oral complications
    --Skin complications
    --Arthropathy
    --Other (specify)

Coagulopathy

• Specify type:
    --Disseminated intravascular coagulation
    --Hereditary factor VIII deficiency
    --Hereditary factor IX deficiency
    --Von Willebrand’s disease
    --Hereditary factor XI deficiency
    --Hereditary deficiency of other clotting factors
    --Acquired coagulation factor deficiency
    --Primary thrombophilia
    --Activated protein C resistance
    --Prothrombin gene mutation
    --Other primary thrombophilia
    --Other thrombophilia
    --Antiphospholipid syndrome
    --Lupus anticoagulant syndrome
    --Other Specified coagulation defects
• Document any associated diagnoses/conditions
• Hemorrhagic disorder due to circulating anticoagulants
    --Due to intrinsic circulating anticoagulants, antibodies, or inhibitors
    --Acquired hemophilia
    --Antiphospholipid antibody with hemorrhagic disorder
    --Other hemorrhagic disorder due to intrinsic circulating
anticoagulants, antibodies, or inhibitors
    --Hemorrhagic disorder due to extrinsic circulating anticoagulants
    --Document specific drug, if drug-induced

Purpura

• Specify if “Allergic purpura” is present and note the following:
    --Allergic vasculitis
    --Nonthrombocytopenic hemorrhagic purpura
    --Nonthrombocytopenic idiopathic purpura
    --Purpura anaphyloctoid
    --Purpura Henochi
    --Purpura rheumatica
    --Vascular purpura
• Document if “Qualitative platelet defects” is present
• Specify if “Other nonthrombocytopenic purpura” is present
    --Purpura not otherwise specified
• Document if any of the following are present:
    -- “Immune thrombocytopenic purpura”
    --“Other primary thrombocytopenia”
    --Evans Syndrome
    --Congenital and/or Hereditary thrombocytopenia
    --“Secondary thrombocytopenia”
    --Posttransfusion pupura
    --Other secondary thrombocytopenia
• Document “Other specified hemorrhagic conditions”
    --Capillary fragility (hereditary)
    --Vascular pseudohemophilia
• Document any associated diagnoses/conditions