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

Hepatitis, MRSA/MSSA and Herpes Simplex Documentation

Hepatitis

Hepatitis

 

• Document acuity:

    --Acute

    --Chronic

• Document etiology:

    --Alcoholic

    --Drug (specify)

    --Viral (Type A, B, C, or E)

• Document also:

    --With hepatic coma

    --Without hepatic coma

    --With delta agent

    --Without delta agent

• Document any associated diagnoses/conditions

 

 

MRSA/MSSA

 

Methicillin-resistant Staphylococcus aureus

• Include documentation of “MRSA infection” when the patient has that

condition.

• Document if sepsis and/or septic shock is present.

• Document any associated diagnoses/conditions.

Methicillin susceptible Staphylococcus aureus

• Include documentation of “MSSA infection” when the patient has that

condition.

• Document if sepsis, and/or septic shock is present.

• Document any associated diagnoses/conditions.

Herpes Simplex

• Specify if “Eczema herpeticum” is present.

• Document if “Herpesviral vesicular dermatitis” is present

    --Herpes simplex facialis

    --Herpes simplex labialis

    --Vesicular dermatitis of ear or lip

• Document if “Herpesviral gingivostomatitis and pharyngotonsillitis”

are present

• Document if “Herpesviral meningitis” is present

• Specify if “Herpesviral encephalitis” is present

• Simian B disease

• Document if “Herpesviral ocular disease” is present

    --Herpesviral iridocyclitis

    --Herpesviral keratitis

    --Herpesviral conjunctivitis

• Specify if “Disseminated herpesviral disease” is present

• Document if “Other forms of herpesviral infections” are present

    --Herpesviral hepatitis

    --Herpes simplex myelitis

    --Other herpesviral infection

    --Herpesviral whitlow

• Document any associated diagnoses/conditions

Systemic Infection/Inflammation, Viral and Bacterial Meningitis

Systemic Infection/Inflammation

Systemic Infection

• Bacteremia (positive blood cultures only)

• Urosepsis—MUST specify sepsis with UTI, versus UTI only

• Sepsis—specify causative organism if known

• Sepsis due to:

     --Device

     --Implant

     --Graft

     --Infusion

     --Abortion

• Severe sepsis—sepsis with organ dysfunction

     --Specify organ dysfunction

     --Respiratory failure

     --Encephalopathy

     --Acute kidney failure

     --Other (specify)

• SIRS (Systemic Inflammatory Response Syndrome

     --With or without organ dysfunction

• Document septic shock if present

• Document any associated diagnoses/conditions

Viral Meningitis

• Documentation of “Viral Meningitis” should include the specific viral

organism if known (i.e., adenovirus, enterovirus, chickenpox, measles,

etc.).

• Document any associated diagnoses/conditions

Bacterial Meningitis

• Documentation of “Bacterial meningitis” should include the specific

bacterial organism (i.e., Escherichia coli, bacillus, gram-negative,

Klebsiella, staph, strep, etc.) if known.

• Document if the meningitis is due to “other causes,” which can include

“nonpyogenic meningitis,” “chronic meningitis,” “Benign recurrent

meningitis.”

• Document any associated diagnoses/conditions