Anemia
Improving physician documentation specificity
- Document status: Acute, chronic or acute on chronic
- Link to underlying disease process
- Gastrointestinal
- Site, if known (e.g., stomach, duodenum, hemorrhoids)
- Etiology (e.g., inflammation, varices, ulcer, angiodysplasia, Crohn's)
- Anemia of chronic disease
- Specific stage of chronic kidney disease
- Neoplasm: “related” or “due to” chemotherapy or radiotherapy treatments
- Acute blood loss
- Dysfunctional uterine bleeding
- Gastrointestinal (see above)
- Post-partum anemia
- Related to surgery (e.g., post-operative anemia due to acute blood loss). This is not a complication if the anemia is expected.
- Trauma
- Nutritional
- Iron deficiency by type (e.g., sideropenic iron deficiency anemia, poor iron absorption, inadequate iron intake)
- Megaloblastic anemia
- B12 deficiency by type (e.g., intrisinsic factor deficiency, transcolbalamin II deficiency, inadequate B12 intake, malabsorption with proteinuria)
- Folate deficiency by type (e.g., diet, drug-induced)
- Protein deficiency anemia
- Hemolytic
- Hereditary or acquired
- Auto-immune or non-auto-immune
- Enzyme disorders
- Glucose-6-phosphate dehydrogenase
- Glutathione metabolism
- Glycolytic enzymes
- Nucleotide metabolism
Thalassemias – alpha, beta, delta-beta, thalassemia minor, hereditary persistence of fetal hemoglobin, hemoglobin E-beta thalassemia, sickle cell thalassemia (with or without crisis)
Aplastic
- “Acquired pure red cell aplasia,” chronic or transient
- Constitutional – congenital, idiopathic or acquired
- Drug-induced (state if drug is agent for cancer chemotherapy), radiation or induced from other external agent
- Idiopathic
Pancytopenia or myelophthisis, if also present
Sideroblastic anemia
- Hereditary (e.g., congenital dyserythropoietic anemia)
- Secondary to disease
- Secondary to drugs and toxins
Adult (main)|Pediatrics (main)
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