Always document the type of “anemia” as a separate problem from its cause.
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
- Ex: Prob #1 – GI Bleed due to diverticulosis
- A transfusion is not required to make this diagnosis
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 |
Download the complete tip, Anemia.