Anemia

Acute Blood Loss Anemias:

• If a patient is anemic after an MVA, GSW, GI Bleed, Epistaxis, Laceration, Hematoma, Hematuria, Abnormal Uterine Bleeding, etc., that anemia is due to acute blood loss and should be  documented as a separate problem from what caused it.
  • Ex: Prob #1 – GI Bleed due to diverticulosis
    Prob #2 – Acute Blood Loss Anemia due to GI Bleed
  • Ex: Prob #1 – Retroperitoneal Bleed due to warfarin
    Prob #2 – Acute Blood Loss Anemia due to Retroperitoneal Bleed
• A transfusion is not required to make this diagnosis
• To reflect weight loss and poor nutrition that do not reach the threshold of malnutrition, consider diagnosing cachexia.
• To reflect inactivity, consider diagnosing age-related physical debility

Chronic Anemias:

• Should always have the cause documented if known
• Please document a likely cause as opposed to a pathological description

• Clinical language that does NOT support your patients’ severity of illness
• Highly effective terminology that accurately reflects your patients’ acuity
• Hypochromic, microcytic anemia
• Iron deficiency anemia