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)|
|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.