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If You Write
Consider
ACS w/elevated troponin
Non-Q wave MI
Any Infection, Bacteremia
(e.g. C.difficile colitis.
Appendicitis, peritoneal abscess
Sepsis if pt. has SIRS (WBC>14k,
“left shift”, temp>101, HR>90,
AMS,
due to that infection
Albumin 3.0, underweight
Mild/Moderate/Severe
malnutrition
Altered Mental Status
Document alteration (Acute
confusion, delirium, psychosis,
dementia, coma) any probable
underlying encephalopathy
(toxic, septic, metabolic,
traumatic, hypoxic hypertensive)
& other brain diseases present
(Alzheimer’s, late effect of stroke,
1 or 2 Parkinson’s)
Amiodarone/AICD use
Underlying rhythm disturbance
Asthmaticus, Status
Acute Resp. Failure if present
Azotemia, Cr  from 1.0 to 2.0
mg/dl. Acute Kidney Injury
Acute Renal Failure AKI criteria
of acute rise of CR>0.3 mg/dl w/I
48 hr: otherwise acute renal
insufficiency
Blunt Abd. Trauma w/ deep injury
If You Write
Acute peritoneal injury + how
solid organ was injured
Consider
CAD/ Angina
Document Stable Angina,
Angina at rest or Progressive
Angina if present
Cardiac Arrest
Its cause : V-Fib/V-Tach /AMI
Chest Pain
CHF
Closed Head Injury
Cocaine/Illegal Drug Use
Alcohol or Marijuana Use
Type of pain (angina, pleuritic,
heartburn, biliary colic), its
probable cause( ie:GERD,
gallstones, cocaine), & if at rest
or accelerated
Acute/Chronic, Systolic or
Diastolic CHF
(decompensated does not
count!!!!!)
Concussion, LOC X _____min
Drug (cocaine) intoxication with
continuous dependency
(Document accompanying angina,
psychosis, toxic encephalopathy,
arrhythmias, accelerated HTN ,
etc.)
Continuous chemical
dependency (if use is recurrent
w/ health consequences or if on
chronic RX i.e. methadone
If You Write
Consider
Chronic Renal
Insufficiency or Failure
Chronic Kidney Disease (CKD)
& stage I, II,III,IV,V or ESRD
based on GFR/Dialysis
COPD/Chronic Bronchitis
Document if stable or exacerbated
Debridement of skin
Describe if Excisional and
deepest level excised.
Diabetes
Diabetes Type 1 or 2 (no more
NIDDM OR IDDM)
Type 2 on Insulin
Diabetes, poorly controlled
Uncontrolled Diabetes, if
multiple BS>250, Hgb A1c >7.
 Hct 2 GI Bleeding/Surg
Acute Blood Loss Anemia
Hypertensive Emergency
Accelerated or Malignant HTN
Hypotension
state UNDERLYING cause i.e.:
hypovolemia, autonomic
K+ 2.0
Hypokalemia due to__________
LLL infiltrate, TX w/ Zosyn
Probable Gram-neg. pneumonia
Na= 125
Hyponatremia & probable cause
(i.e.: diuretics, SIADH)
If You Write
Consider
Pneumonia
Hospital/SNF/Community
acquired/Ventilator-associated
And UNDERLYING organism
i.e.: aspiration, MRSA
Seizure
Describe probable Underlying
cause i.e.: old CVA, Alcohol
withdrawal, epilepsy
Syncope
LOC probably due to _________
Urosepsis
Sepsis due to UTI
PH 7.25 pC02 34 p02 80
Metabolic Acidosis + cause
Neutropenic Fever
Underlying systemic infection
(sepsis) or bacterial infection for
which antibiotics are prescribed.
I.e.: Fungemia rx-capsofungin
Rhythm Stable
Underlying arrhythmia i.e.:
V-Tach, PAT on monitor or
treated
Ranson’s Criteria met
SIRS 2 to Pancreatitis + organs
affected
Pleural Effusion
State probable underlying
condition i.e.: empyema, chronic
CHF or condition to be ruled out
TB, Metastatic CA