low hgb in the postoperative patient

Unknown

There is a surgeon that documents "dilutional" after the low hgb result such as 7.6, dilutional. He does not document anything about anemia; this patient was an 18 year old that had an open chole. with a large intraoperative hematoma. He does not give her blood, but pt was in ICU overnight and they did frequent lab draws.

Would you query for an acute blood loss anemia or a dilutional anemia?

Thanks.

catladyrn

Depending on what the pt's baseline H/H was, given the hematoma you mention, I might consider asking about precipitous drop in hematocrit if the doc digs in his heels. Do you have a high EBL or drain output to go with the hematoma? Often if they are ascribing low H/H to hemodilution from fluid resuscitation, they don't like to go for an anemia, even if we think it's clinically warranted.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center