Choose words carefully to capture the true severity of illness (SOI) for your patient:
No SOI | Moderate SOI | High SOI |
Stool with + occult blood | GI Bleeding Melena | GI Bleeding from DEFINED site (e.g. PUD) |
GERD Esophagitis | Acute esophagitis Esophageal ulcer | Esophageal ulcer with bleeding or Mallory-Weiss |
Don’t forget to document the associated acute blood loss anemia as a separate problem in addition to the GI bleed that caused it.