1. HEART AND CARDIOVASCULAR SYSTEM DISEASES
Identify a cause-and-effect relationship when heart disease is
associated with hypertension (e.g., hypertensive heart disease).
Note any administration of tPA (include if given within 24 hrs. of admit)
Include details of previous MI if applicable (e.g., prior MI in 1998, AMI two
weeks ago, etc.).
List the following when related to cardiovascular conditions:
- Obesity/morbid obesity and include Body Mass Index (BMI).
- Tobacco use, abuse, dependence, past history, or smoke exposure
Clarify when a sign, symptom or abnormal finding is related to a specific condition or disease process.
Provided By: Clinical Documentation Improvement

2. Has Your Patient had an MI?
If so, please remember to document
Type STEMI or nonSTEMI
Site Anterior/Inferior wall, LMC, LAD, RCA, other
Document any recent Acute MI within 28 days
Document any associated conditions or diagnoses
Acute Coronary Syndrome (ACS) is a broad spectrum term encompassing multiple diagnoses. If documented, additional clarification as to the specific event or condition leading to the ACS is needed.
Opac pic
Provided By: Clinical Documentation Improvement

3. HYPERTENSION Identify hypertension as being:
- Essential
- Secondary
Link hypertension to heart disease if applicable.
Identify the type of any heart failure ( e.g., acute systolic).
Hypertensive chronic kidney disease.
- List the stage of chronic kidney disease
- Hypertensive heart and chronic kidney disease
• List any related tobacco use, abuse, dependence, past history,
or smoke exposure (e.g., second hand, occupational, etc.).
HYPERTENSION
Provided By: Clinical Documentation Improvement

4. Has Your Patient Suffered a Cardiac Arrest?
If so, Please remember to document:
Any underlying condition
Specify if arrest was following or during surgery
Any underlying cardiac conditions
Any associated diagnosis and conditions
Provided By: Clinical Documentation Improvement

5. Does your patient have Chest Pain?
If so, Please document:
The probable, possible, or suspected underlying cause or if known, list the definitive diagnosis:
Chest pain likely due to Pleurisy .
Chest pain secondary to ischemic heart disease.
Patient presents with chest pain, suspect esophageal spasm .
Identify if associated with the use of alcohol, drugs, medications or other environmental influences.
State if suspected to be of a psychosomatic nature (e.g., anxiety- induced chest pain).
Clarify when a sign, symptom or abnormal finding is associated with the chest pain or causative condition.
Provided By: Clinical Documentation Improvement

6. Does your patient have CHF?
If so, remember to document
Acuity acute, chronic, acute on chronic
Type systolic, diastolic, combined
Associated Conditions “Due to “ HTN, valvular disease, pericarditis, other
Provided By: Clinical Documentation Improvement