• Document current episode as: Hypomanic, Manic, Depressed, or Mixed
• If current episode is manic or depressed, document
  • Mild, moderate, or severe
  • With or without psychotic features
• If patient is in remission, document:
  • Full versus partial remission
  • Most recent episode as hypomanic, manic, . . .

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• Document specific drug used/abused
• Frequency (use, abuse, dependence, in remission)
• State “no related complications,” when applicable
• Specify intoxication/withdrawal as “uncomplicated” or “with delirium"
• Document any related mood disorder (anxiety or delirium)
• Document any delusions, hallucinations, psychotic . . .

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For typhoid fever, document any associated complications, such as: Pneumonitis, Meningitis
For paratyphoid fever, document type as: Type A, B, or C

Adult (main)|Pediatrics (main)

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Document severity: Acute, Chronic
Document site: Respiratory (lung, larynx, trachea, etc.), Nervous system (meninges, brain, spinal cord, etc.)

Adult (main)|Pediatrics (main)

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Document if methicillin-resistant (MRSA) or methicillin-sensitive (MSSA)
Document if septic shock is present

Adult (main)|Pediatrics (main)

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Sepsis

• Document your intended diagnosis by distinguishing between sepsis, septicemia, or severe sepsis
• Document underlying infection when known
• Do not use sepsis syndrome

Severe sepsis

• Document septic shock, when present.
• Document any associated organ dysfunction (e.g., acute kidney . . .

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