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


GI Bleeding from DEFINED site (e.g. PUD)


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.

Download the complete tip, GI Bleed.