PAST MEDICAL HISTORY
DOCUMENT RECENT CHEST PAIN / ANGINA
DOCUMENTATION FOR CVA PATIENTS IF
RESIDUAL DEFICIT PRESENT
DOCUMENTATION OF MI WITHIN 6 MONTHS
VS. LONGER
"SUBSTANCE USE DISORDER"
OR "ALCOHOL USE DISORDER" WHEN 2 OR MORE OF FOLLOWING:
·
Loss of control over drug/alcohol use
·
Investing large amounts of time obtaining substances
·
Cravings
·
Continued use in spite of relationship conflicts
·
Risk-taking, such as using while driving
·
Continued use in the face of developing health problems
·
Increasing tolerance levels
·
Loss of interest in activities once enjoyed
·
Withdrawal episodes
·
Failed attempts to stop using
·
Failing to meet obligations (work, home, school)
HOSPITAL EVENTS / COMPLICATIONS
ACUTE KIDNEY INJURY – STAGE 3--ABRUPT DECREASE IN KIDNEY
FUNCTION WHILE INPATIENT
*SCr 3 TIME BASELINE OR
SCr TO ≥ 4.0 mg/dl OR
INITIATION OF RENAL REPLACEMENT
THERAPY OR
URINE OUTPUT <.3 ML/KG/H FOR
> 24 HOURS, OR ANURIA FOR > 12 HOURS
ALCOHOL WITHDRAWAL SYNDROME – MUST BE DOCUMENTED IN CHART
SUPERFICIAL INCISIONAL SURGICAL SITE INFECTION
SKIN AND SUBCUTANEOUS INCISION
INFECTION WITHIN 30 DAYS OF OPERATIVE PROCEDURE
DEEP SURGICAL SITE INFECTION – REQUIRES DOCUMENTATION
*INFECTION WITH 30-90 DAYS (TYPE OF
SURGERY DEPENDENT) AND
*INVOLVING DEEP SOFT TISSUES AND
*DRAINAGE, DEHISCENCE OR REQUIRING
OPEN ASPIRATION AND
*FEVER, TENDERNESS, AND/OR ABSCESS
ORGAN / SPACE SURGICAL SITE INFECTION – WITHIN 30 -90 DAYS
OF PROCEDURE
INVOLVING DEEPER
THAN FASCIAL/MUSCLE LAYERS
DUE TO PROCEDURE
DRAINAGE, CULTURE OR ABSCESS Published 12/20/18 (T Cooper, S Priest, A Bernard); Reviewed 9/26/24 (A Bernard, T Cooper)
