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
Melena |
GI Bleeding from DEFINED site (e.g. PUD) |
| GERD
Esophagitis |
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.