Gastrointestinal (GI) Bleeding [Documentation Suggestions]

  • Describe clinical signs and symptoms (e.g., dizziness, orthostatic hypotension, fatigue, pallor, etc.).
  • Document work-up (e.g., colonoscopy, CBC, esophagogastroscopy, etc.).
  • Note source of bleed, if known (e.g., erosive gastritis, angiodysplasia, stomach ulcer, diverticular disease, colon polyp, etc.). If listing possible source, include enough documentation to support the probability.
  • Document treatment (e.g., gastric tamponade, electrocoagulation, polypectomy, etc.).
  • Note any blood loss anemia, specifying whether acute or chronic in nature. Also, note whether patient admitted for treatment of anemia, control of the GI bleed, or for identification or treatment of the source of the bleed.

Additional notes:



Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: 7/7/03)