HEART AND CARDIOVASCULAR SYSTEM DISEASES Identify a cause-and-effect relationship when heart disease is associated with hypertension (e.g., hypertensive heart disease). Note any administration of tPA (include if given within 24 hrs. of admit) Include details of previous MI if applicable (e.g., prior MI in 1998, AMI two weeks ago, etc.). List the following when related to cardiovascular conditions: - Obesity/morbid obesity and include Body Mass Index (BMI). - Tobacco use, abuse, dependence, past history, or smoke exposure Clarify when a sign, symptom or abnormal finding is related to a specific condition or disease process. Provided By: Clinical Documentation Improvement

Has Your Patient had an MI? If so, please remember to document Type STEMI or nonSTEMI Site Anterior/Inferior wall, LMC, LAD, RCA, other Document any recent Acute MI within 28 days Document any associated conditions or diagnoses Acute Coronary Syndrome (ACS) is a broad spectrum term encompassing multiple diagnoses. If documented, additional clarification as to the specific event or condition leading to the ACS is needed. Opac pic Provided By: Clinical Documentation Improvement

HYPERTENSION Identify hypertension as being: - Essential - Secondary Link hypertension to heart disease if applicable. Identify the type of any heart failure ( e.g., acute systolic). Hypertensive chronic kidney disease. - List the stage of chronic kidney disease - Hypertensive heart and chronic kidney disease • List any related tobacco use, abuse, dependence, past history, or smoke exposure (e.g., second hand, occupational, etc.). HYPERTENSION Provided By: Clinical Documentation Improvement

Has Your Patient Suffered a Cardiac Arrest? If so, Please remember to document: Any underlying condition Specify if arrest was following or during surgery Any underlying cardiac conditions Any associated diagnosis and conditions Provided By: Clinical Documentation Improvement

Does your patient have Chest Pain? If so, Please document: The probable, possible, or suspected underlying cause or if known, list the definitive diagnosis: Chest pain likely due to Pleurisy . Chest pain secondary to ischemic heart disease. Patient presents with chest pain, suspect esophageal spasm . Identify if associated with the use of alcohol, drugs, medications or other environmental influences. State if suspected to be of a psychosomatic nature (e.g., anxiety- induced chest pain). Clarify when a sign, symptom or abnormal finding is associated with the chest pain or causative condition. Provided By: Clinical Documentation Improvement

Does your patient have CHF? If so, remember to document Acuity acute, chronic, acute on chronic Type systolic, diastolic, combined Associated Conditions “Due to “ HTN, valvular disease, pericarditis, other Provided By: Clinical Documentation Improvement