Pancreatitis

Diagnosis: Pancreatitis

Applicable for MSDRGs: 438, 439, 440

MD documentation should address:

1. Presenting symptoms: Abd pain and quality; fever or hypothermia; vomiting + frequency; tx incl meds; ETOH or NSAID use
2. CXR findings: (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. Radiologic Findings: evidence of pancreatitis; biliary obstruction; bowel stasis, ileus or obstruction
4. EKG: new findings and subsequent changes – relation to abnormal electrolytes; indication of myocardial ischemia/infarction
5. O2 Sat or ABG Findings (acidosis/alkalosis; pH; hypoxemia if present)
6. Lab values: Amylase; Lipase; other tests with evidence of pancreatitis; electrolyte or coagulation abnormalities (DO NOT USE ARROWS)
7. Pancreatitis: acute; chronic or acute-on-chronic
8. 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
9. Electrolyte or Coagulation abnormalities
10. Renal failure (acute, chronic or acute on chronic, ATN) and any relationship between RF and dehydration
11. Evidence of Dehydration and cause if known
12. Evidence of encephalopathy and cause if known (metabolic, specific organ dysfunction)
13. Treatment with medications, procedures or therapies

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