Did you know? There are no ICD-10 codes for the organ-system approach to medical record documentation.
Ex: Very sick patient for which no codes can be assigned to this record as is currently documented.
| Assessment and Plan | Corresponding ICD-10 Code |
| 1. ID – Continue broad spectrum ABX/fluid resuscitation. Cxs pending | none |
| 2. Cardiovascular – BP now stable off pressors | none |
| 3. Pulmonary – Continue vent at current settings | none |
| 4. Renal – Creatinine now at baseline, monitor | none |
| 5. Endocrine – BSs now controlled on home insulin | none |
| 6. Heme – H&H stable. Iron studies pending | none |
You must list specific diagnoses for which there are corresponding codes in the ICD system if you hope to receive the credit you deserve for the work you do.
Ex: Very sick patient for which the severity of illness can be accurately reported.
| Assessment and Plan | Corresponding ICD-10 Code |
| 1. Sepsis – Continue broad spectrum ABX/fluid resuscitation. Cxs pending | A41.9 |
|
2. Septic Shock – BP now stable off pressors |
R65.21 |
|
3. Acute Hypoxic Respiratory Failure – Continue vent at current settings |
J96.01 |
|
4. Acute Kidney Failure on CKD, stage 3 – Creatinine now at baseline, monitor |
N17.9 & N18.3 |
|
5. DM, Type 2 with hyperglycemia – BSs now controlled on home insulin |
E11.65 |
|
6. Anemia – H&H stable. Iron studies pending |
D64.9 |
Download the complete tip, Documentation Using a Diagnosis-Specific Approach.