New acceptable admission diagnoses:

Cardiac

Not acceptable New acceptable terms
Atrial fibrillation Atrial flutter
Syncope

Always document what you believe to be the cause chiefly responsible for the syncopal episode and link it to it.  Very much like chest pain, you should document the most “probable, possible” cause.  
Examples include:

  • syncope secondary to dehydration

  • syncope secondary to arrhythmia (sinus bradycardia, Sick Sinus, etc.)

  • syncope secondary to vasovagal reaction

  • syncope secondary to postural hypotension

  • syncope secondary to probable medication effect

  • syncope secondary to structural heart disease/ valvular heart disease

ACS or Angina
  • Always document what you believe to be the cause chiefly responsible for the angina/chest pain and link it to it!  Angina and CP (R/O MI) are symptoms, not diagnoses.
  • If you are not certain of the cause but have a reasonable clinical suspicion then use the terms “secondary to probable/possible/?…” 
  • If you have ruled out MI, then document upon discharge what alternative diagnosis you believe responsible for the chest pain.  Make it known what you are thinking! 
CHF Acute systolic or acute diastolic heart failure               
§Always make it clear when preexisting medical problems become active again.  For example, don’t write “h/o CHF” if you are actively treating it.  Document “Acute on chronic systolic/diastolic CHF.”
Chest pain

Correct examples include:
CP/Angina secondary to CAD
(never write angina alone – it means the same as unspecified CP!)

  • Unstable angina secondary to CAD

  • CP secondary to probable GERD/Gastritis/PUD/HH/Dyspepsia

  • CP secondary to ? anxiety/depression/somatization

  • CP secondary to Pleurisy

  • CP secondary to SVT/AFIB/Sinus Tachycardia

  • CP secondary to possible costochondritis/musculoskeletal strain

Pulmonary

Not acceptable Acceptable

Asthma or
COPD Exacerbation
 

Acute bronchitis, tracheobronchitis, URI.  COPD alone suggests a stable, chronic condition.

§

Acute or chronic respiratory failure secondary to asthma
Acute exacerbation of chronic respiratory failure secondary to asthma
Acute or chronic respiratory failure secondary to COPD
Acute exacerbation of chronic respiratory failure secondary to COPD

Acute Respiratory Failure is defined by:
New onset of significant respiratory distress associated with tachypnea (RR>26), hypoxemia (pO2<60), respiratory acidosis (pCO>50 or pH <7.3), or respiratory alkalosis (pH >7.5).
Respiratory Failure may be present even if the pt DOES NOT require intubation!
All patients requiring BIPAP acutely meet this definition.
 “Respiratory Distress” in not adequate documentation.”

Chronic Respiratory Failure is defined by:
 Dependence on home supplemental O2.
 Acute on Chronic Respiratory Failure is defined by:
 Further deterioration in respiratory status from already poor baseline (dependence on home O2), associated with a drop in PaO2 >10 or increasing CO2 from baseline.

Pneumonia Specify type:
Not all pneumonias should be documented as CAP!   We treat very sick patients with more complex PNA’s.
If you suspect Aspiration PNA, Gram NEG PNA, or MRSA PNA, and direct your antibiotics accordingly, then call it “probable/possible/? Aspiration PNA, Gram PNA, or MRSA PNA”.
You don’t have to have positive sputum or blood cx’s, just the appropriate clinical picture (but if you do, don’t forget to link it to the PNA).

Other

Not acceptable Acceptable
Renal insufficiency Acute renal failure
                  or
Acute on chronic renal failure

Acute Renal Failure is defined by either:
An increase in Cr. by 1.5 X normal baseline (if baseline Cr. is .8, an increase to 1.2 would signify ARF)
                   or
Oliguria for ≥ 6 hrs

Acute on Chronic Renal Failure is defined by:
A rising Cr. above an already abnormal baseline (CKD).

UTI (as primary dx) Sepsis secondary to urinary track infection
Catheter associated UTI
Vomiting and/or
diarrhea
Dehydration secondary to vomiting and/or diarrhea
Anemia
§

It is important to convey the cause of the anemia. 
Anemia secondary to blood loss may be written in the following ways and SHOULD NOT be documented as “iron deficiency anemia:”

  • anemia secondary to acute blood loss

  • anemia secondary to chronic blood loss

  • anemia secondary to post-op blood loss

the common causes include:

  • anemia secondary to chronic kidney disease

  • anemia secondary to malignancy (state type of cancer)

  • anemia secondary to chronic disease

 


New acceptable symbols

Not acceptable Acceptable
r/o ?, probable or possible
increased
decreased