Disease Specific Documentation Improvement to help guide between Observation services and Inpatient status

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Postby admin » Tue Mar 28, 2017 9:56 am

Arrhythmia to include all:
Worsening of a previously controlled arrhythmia, and Antiarrhythmic medications (includes PO), and
Continuous cardiac monitoring (excludes Holter)
Bleeding to include one:
Active bleeding with transfusion or factor replacement or H/H monitoring at least 3x/24h, or
Excessive intraoperative blood loss with H/H monitoring at least 3x/24h and IV fluids (need
specific CC or percentage of preoperative from H/H baseline)
Delayed recovery from anesthesia* to include one: Assessment and monitoring at least q4h, or
O2 sat ≤ 91% and < baseline requiring supplemental oxygen
*Delayed recovery from anesthesia includes:
- Unstable level of consciousness
- Mental status changes
- Delayed return of sensation
- Deficit in mobility or coordination
- Hypercapnia or hypoventilation
- Persistent/sustained** hypotension
- Persistent/sustained** vomiting
- Urinary retention
**Sustained refers to a prolonged finding, such as a heart rate or respiratory rate, and excludes
an isolated reading or transient abnormal vital sign measurement. Vital sign measurements should be
repeated at regular intervals to confirm sustained abnormal or normal values.
Pain uncontrolled (pain persists after PACU recovery time) to include all: Pain assessment, and
Analgesic (IM/IV) ≥ 2x/24h
Spinal headache treatment to include one: Epidural blood patch ≤ 24h, or
IV caffeine and fluid
Unable to void and requiring urinary catheter (post procedure/change from baseline/unexpected based
on procedure—requires documentation and treatment)
Vomiting, uncontrolled to include all:
Antiemetic (≥ 2x/24h or serotonin antagonist), and
IV fluids (≥75 cc/hr if age ≥ 65 or weight < 60 kg; ≥ 100 cc/hr and weight
≥ 60 kg)


Documentation supporting any of the following conditions:
Cardiac biomarkers positive (use ACS subset)
Bleeding and blood product transfusion to include ≥ one:
Chest pain or
Dyspnea or
Heart rate > 100 and postural hypotension and sustained drop in BP within 3 min of sitting or standing and SBP drop > 20 or DBP drop > 10
Complex wound care ≥ 3x/day and > 30 min in duration
High risk for thromboembolism requiring anticoagulant therapy (refer to VTE order set)
Hyperkalemia (new onset) to include all:
Potassium > 6.0 and
ECG changes consistent with hyperkalemia and
Intervention: calcium chloride or calcium gluconate or glucose 50% with insulin or Kayexalate PO or PR
Hypokalemia to include all:
Potassium < 3.0 and
PVCs > 6/min and
Potassium chloride: ≥ 10 mEq/h or ≥ 120 mEq/24h
IV medication administration to include all:
Medication (excludes PO): antiarrhythmic or anticonvulsant or antihypertensive or calcium channel blocker or beta blocker or diuretic or insulin or vasoactive/inotrope and
Continuous and monitoring q3-4h or bolus q3-4h and monitoring or titration q3-4h and monitoring or titration > q4h and monitoring ≤ 24h
Neurological impairment or condition to include all:
Acute onset or deterioration and
Neurological assessment q3-4h
O2 sat < 89% and oxygen ≥ 40%
Risk factor to include ≥ one:
COPD with bronchodilator ≥ 6x/24h and corticosteroid and respiratory interventions q3-4h or
CHF NYHA Class III or IV and continuous cardiac monitoring or
Sleep apnea requiring NIPPV or
Pre-existing VAD and continuous cardiac monitoring
Symptomatic systolic BP < 100 requiring treatment

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