Expected Mortality CHF, COPD & Afib –WOB, Sats, RR –BiPAP –ABG results –Thin, sunken temples –BP, gtt’s started Expected Mortality Rate: 1.7% CHF, COPD & Afib ADD: –Respiratory Failure –Acidosis –Decubitus ulcer –Malnutrition –Cardiogenic Shock Expected Mortality Rate: 36.3%

Expected Mortality –PNA –Acute COPD –Mortality Rate: 0.3% –PNA –Acute COPD –Add: Malnutrition Decubitis Ulcer –Mortality Rate: 2.3% –PNA –Acute COPD –MODIFY: Malnutrition, SEVERE Decubitis Ulcer, STAGE IV –Mortality Rate: 9.2%

HCAP translates / codes to Simple pneumonia Consider: PNA, possibly due to: gram negative organism Specific suspected organism

The Extra Step: Include ALL chronic conditions –present and stable but managed

Cancer Primary vs Secondary Specify ALL metastatic sites Active … Remission … Resolved –Include all associated diagnoses

Urosepsis translates / codes to Simple UTI Consider: Sepsis from a UTI

The Extra Step: For each medication –Associated diagnosis For each ordered study –Suspected diagnosis

When is a PE resolved?? –If PE is felt still present & being treated: Identify as acute or subacute Even if from a recent admission

ACUTE CHF translates / codes to CHF, not further specified Consider: Specify diastolic &/or systolic Will then capture ACUTE

The Extra Step: For each abnormal finding (Lab, radiology, exam) Describe clinical significance INCLUDE suspected cause NAME IT

ESRD With fluid overload or pulmonary edema –Is it NON-CARDIOGENIC? –Or is it CHF What is the cause (non-compliance?)

END STAGE COPD with continuous home O2 translates / codes to COPD only Consider: COPD, Acute Exacerbation Acute & Chronic Respiratory Failure

The Extra Step: Specify supportive facts for diagnosis Quantify Risk Stratification

History of…?? –Is the condition truly resolved? Or is it chronic & stable with ongoing management

“Post-operative” Frequently translates / codes to complication Caution on intended meaning: Temporal vs Causative relationship Clarify if INTEGRAL to procedure or EXPECTED part of recovery period

The Extra Step: Include ALL diagnosis being considered, worked up or treated “possible”, “probable”, “likely” Update diagnosis status –Ruled in or out –Remains possible

Altered Mental Status: Is it? Acute Confusion Chronic dementia…or acutely worse? Acute delirium Encephalopathy –Include specific suspected causes

Symptoms (dyspnea, chest pain, dizziness, weakness, fever) translates / codes to ???? Explicitly state suspected cause –d/t arrythmia, COPD, CHF, PNA, etc. –d/t unstable angina or CAD, pleurisy, GERD, chest wall pain –d/t hypotension / dehydration –likely source, or bacterial infection unknown source

The Extra Step: Relate conditions & State connections –UTI due to Foley –specific conditions due to prior CVA –Manifestations & Sequela

Manifestations of disease WITHOUT Explicit linkage translates / codes to Uncomplicated DM, HTN Consider – use adjective or “due to” Diabetic nephropathy or Hypertensive CHF

The Extra Step: Carry diagnoses throughout stay Include ALL diagnoses at discharge Acute Chronic Resolved during stay

Condition with “VS” (differential diagnoses) translates / codes to Condition ONLY Consider: 1.Identify primary suspected cause (then follow with alternatives) 2.Clearly indicate RULED IN & OUT diagnoses

Use STRONG terms: Failure Shock Coma Encephalopathy

The Extra Step: Renal Status –CKD Stage? –Acute Renal Failure due to …

Use STRONG Qualification & Links: Acute, Acute on Chronic Sub-acute, Chronic Congenital Exacerbated Uncontrolled Mild, Moderate, Severe Due to, Secondary to Unstable

The Extra Step: Abbreviations –Always spell it out the first & last time –Different areas expertise & knowledge Prevent confusion & errors