Heart Failure, CVA and Myocardial Infarction Documentation

Heart Failure

Heart Failure

• Document acuity
    --Acute
    --Chronic
    --Acute on Chronic
• Document type
    --Diastolic
    --Systolic
    --Combined systolic and diastolic
• Due to or associated with
    --Cardiac or other surgery
    --Hypertension
    --Valvular disease
    --Rheumatic heart disease
       °°Endocarditis (valvitis)
       °°Pericarditis
       °°Myocarditis
    --Other (specify)

CVA

• Due to Hemorrhage
    --Location or source of hemorrhage
       °°Subarachnoid (specify artery, if known)
       °°Intracerebral (specify location, if known)
       °°Intracranial
          »»Subdural
              * Acute, Subacute, Chronic
          »»Extradural
    --Laterality
    --Document any associated diagnoses/conditions
• Due to causes other than hemorrhage
    --Cause
       °°Thrombosis
       °°Embolism
       °°Other (specify)
       °°Unspecified Occlusion or stenosis
    --Site
       °°Precerebral Arteries (specify artery, if known)
       °°Cerebral Arteries (specify artery, if known)
    --Laterality
    --Document any associated diagnoses/conditions

Myocardial Infarction

• Document the type of MI:
    --ST elevation (STEMI)
       °°Requires site and specific artery:
           »»Anterior Wall
               * Left main coronary artery
               * Left anterior descending artery
               * Other coronary artery of anterior wall
           »»Inferior Wall
               * Right coronary artery
              * Other coronary artery of inferior wall
    --Other
       °°Left circumflex coronary artery
       °°Other Specified
    --Non-ST elevation MI (NSTEMI)
       °°Requires episode of care reporting only
• Document date of any recent acute MIs within 28 days of admission
• Document whether or not the current MI has occurred within 28 days
of a previous MI
• Document if the patient has a history of an MI (older than 28 days)
• Document any associated diagnoses/conditions