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Documentation Tip of the Week: Pancreatitis

Posted on Wed, Oct 21, 2015
Documentation Tip of the Week: Pancreatitis

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

Show accurate severity of illness when documenting acute pancreatitis.

If the SIRS criteria are present, be sure to document them.

Examples:
 

  • SIRS secondary to pancreatitis WITHOUT organ dysfunction
  • SIRS secondary to pancreatitis WITH organ dysfunction (ATN, metabolic encephalopathy, severe malnutrition)

Remember, SIRS is defined as ≥ 2 of the following 4 criteria:
 
  • Pulse > 90bpm
  • Temp > 100.4F (38.6C) or < 96.8F (36C)
  • WBC > 12,000 or < 4,000 or Diff > 10% bands
  • RR > 20/min or PCO2 < 32mmHg

This documentation will support your patient being as sick on paper as they are in the bed.

Reference: R. Mofidi, P. V. Patil, S. A. Suttie and R. W. Parks.
“Risk assessment in acute pancreatitis.” British Journal of Surgery 2009; 96: 137–150




Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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