Pancytopenia, Nutritional and Aplastic Anemia Clinical Documentation

Pancytopenia

Pancytopenia

 

• Specify if:
    --Antineoplastic chemotherapy induced pancytopenia
    --Other drug-induced pancytopenia
    --Specify drug
    --Other pancytopenia
• Specify the etiology of pancytopenia (if known), such as:
    --Myelodysplastic Syndrome
    --Leukemia
    --HIV
    --Other (specify)
• Document any associated diagnoses/conditions

 

Nutritional Anemia

 • Iron deficiency anemia

• Iron deficiency anemia secondary to blood loss
    --Acute blood loss anemia
    --Chronic blood loss anemia
• Iron deficiency anemia due to poor iron absorption
• Vitamin B12 deficiency
    --Pernicious anemia
    --Malabsorption with proteinuria
    --Transcobalamin II deficiency
    --Vegan Anemia
• Document Folate deficiency anemia
    --Dietary induced
    --Drug-induced
• “Protein” deficiency anemia
• “Megaloblastic” anemia
• List all secondary comorbidities and complications
• Document any associated diagnoses/conditions

Aplastic Anemia

For aplastic anemia and other bone marrow failure syndromes:
    --Specify if “Acquired pure red cell aplasia”
    --Chronic
    --Transient
    --Other
    --Specify if aplastic anemia is:
    --Constitutional
»»Congenital, idiopathic or acquired
    --Drug-induced, radiation, or induced from other external agent
    --Idiopathic
    --Document pancytopenia or myelophthisis, if also present
• Document if any of the following are present:
    -- “Acute posthemorrhagic anemia”
    --“Anemia in neoplastic disease”
    --“Anemia in chronic kidney disease”
    --“Anemia in other chronic disease”
    --List the chronic diseases
• Document if “Sideroblastic anemia” is:
    --Hereditary
    --Secondary due to disease
    --Secondary due to “drugs and toxins”
    --Congenital dyserythropoietic anemia
• Document if the Anemia is Due to Antineoplastic chemotherapy
• Document any associated diagnoses/conditions