Clinical Documentation Improvement Tip: Coding Help for Hypotension Vs. Shock

67 y.o. male was admitted with a hip fracture and it was decided to do a hip replacement. Intra-operatively the femur bled and the patient lost about 1000 ml of blood. Overnight the patient’s blood pressure, baseline 130s/90s, dropped to 80s/40’s. Heart rate, baseline high 60s & low 70s, increased to 90s & 100s. Hgb on admission was 14 which dropped to 8.2 post-op.

Treatment with vasopressors followed by 500ml/hour until vital signs improved. Placed on 10L O2 & non-rebreather initially and once vital signs stable decreased to 3-4L, Patient was continually monitored in ICU, taking 10 hours to recover.

Documentation stated hypotensive due to 1000ml blood loss.

The CDS wrote a clarification, addressing it to both the surgeon and hospitalist, asking if the event was Hypovolemic Shock, with or without Anemia due to Acute Blood Loss or was the hypotension due to some other etiology.

The surgeon documented in his next note that the patient’s episode was due to Hypovolemic Shock and the Hospitalist documented Anemia due to Acute Blood Loss.

Randy Wagner, BSN, RN, CCS

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