New acceptable admission diagnoses

Cardiac
Not acceptable	New acceptable terms
Atrial fibrillation	Atrial flutter
Syncope	Always document what you believe to be the cause chiefly responsible for the syncopal episode and link it to it. Very much like chest pain, you should document the most “probable, possible” cause. Examples include: syncope secondary to dehydration syncope secondary to arrhythmia (sinus bradycardia, Sick Sinus, etc.) syncope secondary to vasovagal reaction syncope secondary to postural hypotension syncope secondary to probable medication effect syncope secondary to structural heart disease/ valvular heart disease
ACS or Angina	Always document what you believe to be the cause chiefly responsible for the angina/chest pain and link it to it! Angina and CP (R/O MI) are symptoms, not diagnoses. If you are not certain of the cause but have a reasonable clinical suspicion then use the terms “secondary to probable/possible/?…” If you have ruled out MI, then document upon discharge what alternative diagnosis you believe responsible for the chest pain. Make it known what you are thinking!
CHF	Acute systolic or acute diastolic heart failure §Always make it clear when preexisting medical problems become active again. For example, don’t write “h/o CHF” if you are actively treating it. Document “Acute on chronic systolic/diastolic CHF.”
Chest pain	Correct examples include: CP/Angina secondary to CAD (never write angina alone – it means the same as unspecified CP!) Unstable angina secondary to CAD CP secondary to probable GERD/Gastritis/PUD/HH/Dyspepsia CP secondary to ? anxiety/depression/somatization CP secondary to Pleurisy CP secondary to SVT/AFIB/Sinus Tachycardia CP secondary to possible costochondritis/musculoskeletal strain
Pulmonary
Not acceptable	Acceptable
Asthma or COPD Exacerbation Acute bronchitis, tracheobronchitis, URI. COPD alone suggests a stable, chronic condition. §	Acute or chronic respiratory failure secondary to asthma Acute exacerbation of chronic respiratory failure secondary to asthma Acute or chronic respiratory failure secondary to COPD Acute exacerbation of chronic respiratory failure secondary to COPD Acute Respiratory Failure is defined by: New onset of significant respiratory distress associated with tachypnea (RR>26), hypoxemia (pO2<60), respiratory acidosis (pCO>50 or pH <7.3), or respiratory alkalosis (pH >7.5). Respiratory Failure may be present even if the pt DOES NOT require intubation! All patients requiring BIPAP acutely meet this definition. “Respiratory Distress” in not adequate documentation.” Chronic Respiratory Failure is defined by: Dependence on home supplemental O2. Acute on Chronic Respiratory Failure is defined by: Further deterioration in respiratory status from already poor baseline (dependence on home O2), associated with a drop in PaO2 >10 or increasing CO2 from baseline.
Pneumonia	Specify type: Not all pneumonias should be documented as CAP! We treat very sick patients with more complex PNA’s. If you suspect Aspiration PNA, Gram NEG PNA, or MRSA PNA, and direct your antibiotics accordingly, then call it “probable/possible/? Aspiration PNA, Gram PNA, or MRSA PNA”. You don’t have to have positive sputum or blood cx’s, just the appropriate clinical picture (but if you do, don’t forget to link it to the PNA).
Other
Not acceptable	Acceptable
Renal insufficiency	Acute renal failure or Acute on chronic renal failure Acute Renal Failure is defined by either: An increase in Cr. by 1.5 X normal baseline (if baseline Cr. is .8, an increase to 1.2 would signify ARF) or Oliguria for ≥ 6 hrs Acute on Chronic Renal Failure is defined by: A rising Cr. above an already abnormal baseline (CKD).
UTI (as primary dx)	Sepsis secondary to urinary track infection
UTI (as primary dx)	Catheter associated UTI
Vomiting and/or diarrhea	Dehydration secondary to vomiting and/or diarrhea
Anemia	§ It is important to convey the cause of the anemia. Anemia secondary to blood loss may be written in the following ways and SHOULD NOT be documented as “iron deficiency anemia:” anemia secondary to acute blood loss anemia secondary to chronic blood loss anemia secondary to post-op blood loss the common causes include: anemia secondary to chronic kidney disease anemia secondary to malignancy (state type of cancer) anemia secondary to chronic disease

Not acceptable	Acceptable
r/o	?, probable or possible
↑	increased
↓	decreased