Neoplasms, Anemia and Hemolytic Anemia Clinical Documentation

Neoplasms

Neoplasms

• Behavior:

    --Malignant (primary, secondary, in-situ)

    --Document any secondary sites

    --Benign

    --Unspecified behavior

    --Of uncertain histological behavior

• Laterality (specify right/left)

• Anatomical site (topography)

• Other condition(s) associated with malignancy (dehydration, anemia,

etc.)

• Complication(s) associated with neoplasm

• Include estrogen receptor status (if applicable)

• History of:

    --Has the malignancy been excised or eradicated?

    --Is there still treatment being provided for the primary and/or

metastatic site?

    --Is there evidence of remaining malignancy at the primary site?

• Document any associated diagnoses/conditions

Anemia

• Documentation of Anemia should include the type of anemia:

    --Nutritional

    --Hemolytic

    --Aplastic

    --Due to blood loss

    --Other (please specify)

• Include in documentation if Anemia is due to nutrition or mineral deficits,

resulting in a nutritional anemia

• Document if the Anemia is due to a neoplasm (primary and/or

secondary)

• Document whether the ANEMIA is “related to or due to” chemo or

radiotherapy treatments

• Document any “cause–and-effect” relationship between the intervention

and the blood or immune disorder

• Document the specific drug if anemia is drug-induced

• Link any laboratory findings to a related diagnosis (if appropriate)

• Document any associated diagnoses/conditions

Hemolytic Anemia

• Due to “Enzyme Disorders”:

    --Glucose-6-phosphate dehydrogenase

    --Glutathion metabolism

    --Glycolytic enzymes

    --Due to nucleotide metabolism

• Thalassemias:

    --Alpha thalassemia

    --Beta thalassemia

    --Delta-beta thalassemia

    --Thalassemia minor

    --Hereditary persistence of fetal hemoglobin

    --Hemoglobin E-beta thalassemia

• Sickle Cell Disorders is present

    --Specify if “With or Without Crisis”

• Sickle Cell thalassemia

    -- Specify if “With or Without Crisis”

• Include documentation of whether the hemolytic anemia is:

    --Hereditary

    --Acquired

    --Enzyme disorder

    --Autoimmune

    --Non-autoimmune

• Document the disorder/condition causing the anemia

• Document any associated diagnoses/conditions