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
  • 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.