Gastrointestinal Hemorrhage

Diagnosis: Gastrointestinal Hemorrhage

Applicable for MSDRGs: 377, 378, 379

MD documentation should address:

1. Presenting symptoms: abd pain, bloating or distention; hematemesis; diarrhea w/ dark or bloody stools; dysphagia; GERD; long term NSAID/steroid use; hx of GI surgery or PUD
2. CXR findings (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. Radiologic Findings: evidence of GI hemorrhage
4. EKG: new findings and subsequent changes
5. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure)
6. Lab values: Hemoglobin, Hematocrit for evidence of anemia.
   • Positive hemocult stool or emesis
7. Evidence of SIRS: Must have at least 2 of the following:
   • Tachycardia: Pulse>90
   • Tachypnea: RR >20
   • Temp >100.4 (38C) or <96.8 (36C)
   • WBC >12,000 or <4,000 or >10% bands
8. Relationship between GI bleed and anemia if present (acute or chronic blood loss anemia)
9. GI bleed source if known (i.e. GI ulcer; esophageal varices; gastritis; angiodysplasia; diverticulitis; GI neoplasm; or other GI disorder with hemorrhage).
10. Treatment of hemorrhage, including any blood products given for anemia.
11. Procedures performed to determine source of GI bleeding (i.e. colonoscopy; EGD)

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