Behavioral / Social
Actively Exit Seeks
Acute psychosis
Agitated Vocalization
Anxiety / Panic Episodes
Bipolar disorder - Controlled
Bipolar disorder - Symptomatic
Combative w/ Personal Care - Severity ↑ - Occurred 3x or less in last 7 D
Combative w/ Personal Care - Severity ↑ - Occurred 4x or more in last 7 D
Combative w/ Personal Care - ↓ Severity - Occurred 3x or less in last 7 D
Combative w/ Personal Care - ↓ Severity - Occurred 4x or more in last 7 D
Compulsive Hoarding / Collecting
Crying Spells / Tearfulness
Currently under custody of law enforcement
Disinhibited Sexual Behavior - Dementia - Severity ↑ - Occurred 3x or less in last 7 D
Disinhibited Sexual Behavior - Dementia - Severity ↑ - Occurred 4x or more in last 7 D
Disinhibited Sexual Behavior - Dementia - ↓ Severity - Occurred 3x or less in last 7 D
Disinhibited Sexual Behavior - Dementia - ↓ Severity - Occurred 4x or more in last 7 D
Disinhibited Sexual Behavior - IDD - Severity ↑ - Occurred 3x or less in last 7 D
Disinhibited Sexual Behavior - IDD - Severity ↑ - Occurred 4x or more in last 7 D
Disinhibited Sexual Behavior - IDD - ↓ Severity - Occurred 3x or less in last 7 D
Disinhibited Sexual Behavior - IDD - ↓ Severity - Occurred 4x or more in last 7 D
Disinhibited Sexual Behavior - Psych - Severity ↑ - Occurred 3x or less in last 7 D
Disinhibited Sexual Behavior - Psych - Severity ↑ - Occurred 4x or more in last 7 D
Disinhibited Sexual Behavior - Psych - ↓ Severity - Occurred 3x or less in last 7 D
Disinhibited Sexual Behavior - Psych - ↓ Severity - Occurred 4x or more in last 7 D
Disinhibited Speech - High Severity
Disinhibited Speech - Low Severity
Elopement/Wanderer Risk - High Severity
Elopement/Wanderer Risk - Low Severity
Fecal Smearing / Inappropriate Toileting
Gunshot / Stab / Assault Wounds
Hallucinations / Delusions - Mild Reactivity
Hallucinations / Delusions - Moderate Reactivity
Hallucinations / Delusions - Severe Reactivity
Homeless
Huntington's
Other Physical Behavior - High Severity - Occurred 3x or less in last 7 D
Other Physical Behavior - Low Severity - Occurred 3x or less in last 7 D
Other Physical Behavior - Severity ↑ - Occurred 4x or more in last 7 D
Other Physical Behavior - ↓ Severity - Occurred 4x or more in last 7 D
Pending Guardianship
Pregnant
Psychiatric Dx is Primary
Recently incarcerated
Registered Sex Offender: Tier 1
Registered Sex Offender: Tier 2
Registered Sex Offender: Tier 3
Rejection of Care - High Risk - Occurred 3x or less in last 7 D
Rejection of Care - Low Risk - Occurred 3x or less in last 7 D
Rejection of Care - Severity ↑ - Occurred 4x or more in last 7 D
Rejection of Care - ↓ Severity - Occurred 4x or more in last 7 D
SA - High Harm 31-180 days
SA - High Harm in last 30 days (life-threatening / ICU level)
SA - Low Harm 31-180 days
SA - Low Harm in last 30 days (superficial)
SA - Moderate Harm 31-180 days
SA - Moderate Harm in last 30 days (ED care – not critical)
SI - Active (no method) - Current
SI - Active (no method) - Resolved 31-180 days
SI - Active (no method) - Resolved in last 30 days
SI - Method - no intent - Current
SI - Method - no intent - Resolved 31-180 days
SI - Method - no intent - Resolved in last 30 days
SI - Passive - Current
SI - Passive - Resolved 31-180 days
SI - Passive - Resolved in last 30 days
SI - Plan + intent - Current
SI - Plan + intent - Resolved 31-180 days
SI - Plan + intent - Resolved in last 30 days
Schizophrenia - Controlled
Schizophrenia - Symptomatic
Smoking Permitted
Under 18 years of age
Cardiac
Cardiac Drips
Cardiac Drips IV Lopressor
Doppler Studies
EKG's-12 lead in house
Handheld Doppler
LVAD
Life Vest
Pacemaker External Temporary
Pacemaker ICD Internal
Pacemaker Vest
Post CABG Surgery
Post Stent Surgery
Post Valve Surgery
Sequential Compression Stockings - Intermittent pneumatic compression (IPC)
Drains
Aspira Catheter (Pleural/Peritoneal)
Bili
Catheter - external
Catheter - indwelling
Catheter Insertion / Maintenance
Chest Tube
Hemovac
Jackson-Pratt (JP)
Nephrostomy Tube
Penrose
Pleurx
T-Tube Drain
IV Therapy
Antibiotics Drip
Blood Transfusions Onsite / in-house
Blood Transfusions offsite transportation
Central Line / CVAD - med administration & maintenance
Central Venous Line CVC
Draw Blood Venous Sticks
Epidural- External Pump with med administration
Epidural- Internal Pump
Fluid Administration (Hydration)
Heparin Drip
Hypodermoclysis
IV Push Meds
IV dieuretics
Insulin Pump
Intrathecal Lines- External Pumps with med administration
Intrathecal Lines- Internal Pumps
Midline / Groshong / Mediport / Huber Needle
Narcotics Drip
PCA Pumps
Peripheral
Picc Line
Porta-A-Caths (infusion ports)- med administration/accessing/flushing
Infections
Acinobacter
C-Diff
CRE+
Candida Auris
CoVid
HEP A
HEP C
HIV
Hemodialysis Onsite with Isolation
Isolation - airborne
Isolation - contact
Isolation - contact plus
Isolation - droplet
MRSA
Negative Pressure Room Recommended
TB- antibiotic treated with 3 negative tests
TB-Active
VRE
Medications
(Behavioral) Abilify - Aripiprazole
(Behavioral) Clozaril - Clozapine
(Behavioral) Depakote - Sodium valproate
(Behavioral) Geodon - Ziprasidone
(Behavioral) Haldol - Haloperidol
(Behavioral) Lamictal - Lamotrigine
(Behavioral) Lithium Carbonate
(Behavioral) Navane - Thiothixene
(Behavioral) Prolixin - Fluphenazine
(Behavioral) Risperdal - Risperidone
(Behavioral) Seroquel - Quetiapine
(Behavioral) Stelazine - Trifluoperazine
(Behavioral) Tegretol - Carbamazepine
(Behavioral) Thorazine - Chlorpromazine
(Behavioral) Trilafon - Perphenazine
(Behavioral) Zyprexa - Olanzapine
(Cost Potential) ALINIA - Nitazoxanide
(Cost Potential) AMBISOME - Amphotericin B liposomal
(Cost Potential) AMBRISENTAN - Ambrisentan
(Cost Potential) AUBAGIO - Teriflunomide
(Cost Potential) AUSTEDO - Deutetrabenazine
(Cost Potential) AVONEX PEN - Interferon beta-1a
(Cost Potential) AVYCAZ - Ceftazidime/Avibactam
(Cost Potential) AZACTAM - Aztreonam
(Cost Potential) BAXDELA - Delafloxacin
(Cost Potential) BETASERON - Interferon beta-1b
(Cost Potential) BETHKIS - Tobramycin
(Cost Potential) BEXSERO - Meningococcal Group B Vaccine
(Cost Potential) BIKTARVY - Bictegravir/Emtricitabine/Tenofovir alafenamide
(Cost Potential) CASPOFUNGIN ACETATE - Caspofungin
(Cost Potential) CATHFLO ACTIVASE - Alteplase
(Cost Potential) CLINISOL - Amino Acids Injection
(Cost Potential) COMPLERA - Emtricitabine/Rilpivirine/Tenofovir
(Cost Potential) COPAXONE - Glatiramer acetate
(Cost Potential) CRESEMBA - Isavuconazonium sulfate
(Cost Potential) CUBICIN - Daptomycin
(Cost Potential) DALVANCE - Dalbavancin
(Cost Potential) DIFICID - Fidaxomicin
(Cost Potential) DUPIXENT PEN - Dupilumab
(Cost Potential) ENBREL - Etanercept
(Cost Potential) EPIPEN 2-PAK - Epinephrine
(Cost Potential) ERAXIS (WATER DILUENT) - Anidulafungin
(Cost Potential) ERLEADA - Apalutamide
(Cost Potential) ESBRIET - Pirfenidone
(Cost Potential) EUCRISA - Crisaborole
(Cost Potential) EVEROLIMUS - Everolimus
(Cost Potential) FLEXBUMIN - Human Albumin
(Cost Potential) FLUCYTOSINE - Flucytosine
(Cost Potential) FORTEO - Teriparatide
(Cost Potential) FULVESTRANT - Fulvestrant
(Cost Potential) GILENYA - Fingolimod
(Cost Potential) GLUCAGEN - Glucagon
(Cost Potential) GRANIX - Tbo-filgrastim
(Cost Potential) GVOKE HYPOPEN - Glucagon
(Cost Potential) HIZENTRA - Immune Globulin Subcutaneous (Human)
(Cost Potential) HUMIRA - Adalimumab
(Cost Potential) INGREZZA - Valbenazine
(Cost Potential) INVANZ - Ertapenem
(Cost Potential) INVEGA TRINZA - Paliperidone palmitate
(Cost Potential) KEVZARA - Sarilumab
(Cost Potential) LINEZOLID-0.9% NACL - Linezolid
(Cost Potential) LINEZOLID-D5W - Linezolid
(Cost Potential) MICAFUNGIN - Micafungin
(Cost Potential) MINOCIN - Minocycline
(Cost Potential) MOVIPREP - Polyethylene Glycol/Electrolytes
(Cost Potential) MYCAMINE - Micafungin
(Cost Potential) NAFCILLIN - Nafcillin
(Cost Potential) NAYZILAM - Midazolam
(Cost Potential) NEUPOGEN - Filgrastim
(Cost Potential) NINLARO - Ixazomib
(Cost Potential) NORITATE - Metronidazole
(Cost Potential) NOXAFIL - Posaconazole
(Cost Potential) NPLATE - Romiplostim
(Cost Potential) NUPLAZID - Pimavanserin
(Cost Potential) NYMALIZE - Nimodipine
(Cost Potential) ODEFSEY - Emtricitabine/Rilpivirine/Tenofovir alafenamide
(Cost Potential) ODOMZO - Sonidegib
(Cost Potential) ORBACTIV - Oritavancin
(Cost Potential) ORENCIA - Abatacept
(Cost Potential) OTEZLA - Apremilast
(Cost Potential) OXACILLIN SODIUM - Oxacillin
(Cost Potential) PENICILLIN G POTASSIUM - Penicillin G potassium
(Cost Potential) PENICILLIN G SODIUM - Penicillin G sodium
(Cost Potential) PREVYMIS - Letermovir
(Cost Potential) PROMACTA - Eltrombopag
(Cost Potential) PULMOZYME - Dornase alfa
(Cost Potential) RAYOS - Prednisone
(Cost Potential) REBIF - Interferon beta-1a
(Cost Potential) RINVOQ - Upadacitinib
(Cost Potential) SIVEXTRO - Tedizolid
(Cost Potential) SODIUM THIOSULFATE - Sodium thiosulfate
(Cost Potential) SOFOSBUVIR-VELPATASVIR - Sofosbuvir/Velpatasvir
(Cost Potential) SPRYCEL - Dasatinib
(Cost Potential) SYMTUZA - Darunavir/Cobicistat/Emtricitabine/Tenofovir alafenamide
(Cost Potential) TEFLARO - Ceftaroline fosamil
(Cost Potential) TIGAN - Trimethobenzamide
(Cost Potential) TIGECYCLINE - Tigecycline
(Cost Potential) TOLVAPTAN - Tolvaptan
(Cost Potential) TRAVASOL - Amino Acids Injection
(Cost Potential) TRIUMEQ - Abacavir/Dolutegravir/Lamivudine
(Cost Potential) TYGACIL - Tigecycline
(Cost Potential) UBRELVY - Ubrogepant
(Cost Potential) VABOMERE - Meropenem/Vaborbactam
(Cost Potential) VFEND IV - Voriconazole
(Cost Potential) XELJANZ XR - Tofacitinib
(Cost Potential) XERAVA - Eravacycline
(Cost Potential) XTANDI - Enzalutamide
(Cost Potential) ZARXIO - Filgrastim-sndz
(Cost Potential) ZERBAXA - Ceftolozane/Tazobactam
(Cost Potential) ZOFRAN ODT - Ondansetron
(Cost Potential) ZOLEDRONIC ACID - Zoledronic acid
(SUD) Acamprosate - Campral
(SUD) Buprenorphine - Suboxone / Subutex
(SUD) Disulfiram - Antabuse
(SUD) Injectable Naltrexone - Vivitrol
(SUD) Methadone
(SUD) Oral Naltrexone - ReVia
Neurological
Alzheimer Dementia
Closed Head Injury
Frontotemporal Dementia
Lewy Body Dementia
Mixed Dementia
Normal Pressure Hydrocephalus
Parkinson's Dementia
Parkinson's Disease
Picks Disease - behavioral variant FTD (bvFTD)
Spinal Cord Injury
TBI - Mild Tramatic Brain Injury
TBI - Moderate Tramatic Brain Injury
TBI - Severe Tramatic Brain Injury
Vascular Dementia
Wernicke-Korsakoff Syndrome
Nutrition
Corpak Dobhoff
Enteral G-Tube
Enteral J-Tube
Enteral Peg Tube
Gastrojejunostomy Tube
NG Tube
Post Gastric Bypass
TPN Continous
TPN Cyclical 12H
TPN Cyclical 16H
TPN Cyclical 18H
Oncology
Care of patient receiving radiation off site
In-House IV Chemotherapy
Infusions at Standalone Clinic
Infusions attached/billed under hospital npi
PO Chemotherapy administrated in-house
Patient requires stretcher transport to infusions/radiation
Patient requires wc transport to infusions/radiation
Ortho
Amputation
Bone Growth Stimulation
Cervical Traction
Continuous Passive Motion (CPM)
Double Amputation
Halo Traction
Mild Cervical Traction
Skeletal Traction
Total joint replacement/repair
Other
601 – 1 000 lb 1-person assist
601 – 1 000 lb 2-person assist
Bariatric 351 – 450 lb 1-person assist
Bariatric 351 – 450 lb 2-person assist
Bariatric 351 – 450 lb 3-person assist
Bariatric 351 – 450 lb Mechanical Lift
Bariatric 451 – 600 lb 1-person assist
Bariatric 451 – 600 lb 2-person assist
Bariatric 451 – 600 lb 3-person assist
Bariatric 451 – 600 lb mechanical lift
Hemophilia
I & O Monitoring
MR/DD
Motor Vehicle Accident with litigation
Motor Vehicle Accident without litigation
No In-Home Caregiver
No PCP
Non-Citizen
Post Organ Transplant
Under 350 lb 1-person assist
Under 350 lb 2-person assist
Under 350 lb 3-person assist
Under 350 lb Mechanical Lift
Pain
CADD PUMP
Chronic palliative Methadone
Internal Pain Pump
Internal Simulator Pump
PCA/TV
Renal
AV Fistula Shunt Access device monitoring
Bladder Irrigation Continuous
Bladder Scan / Ultrasound Devices Onsite / In-house
Continuous renal replacement therapy (CRRT)
Coude Catheter
Hemodialysis Onsite / In-House
Illeal Conduit Urinary Diversion
Peritoneal Dialysis
Respiratory
Airvo Heated High Flow O2
Bedside Spirometry (PFTs)
CPAP BIPAP
Chest Tubes
Closed endotracheal Suctioning
Flolan Pump
High-Flow Nasal Cannula (HFNC): 20-60 LPM (FiO2 up to 100%)
Laryngectomy Tubes
Nasal Cannula: 1-6 LPM (FiO2 ~24-44%)
Oral Suctioning
Percussion Vest
Put on/Remove Passe Muir Valve
Simple Face Mask: 6-10 LPM (FiO2 ~35-60%)
Sterile Technique Endotracheal suctioning
Suctioning multiple times per hour
Suctioning q1h
Suctioning q2h
Suctioning q3h
Suctioning q4h
Trach – New placed in last 14 days
Trach – stable in place >14 days
Trachs with onsite hemodialysis
Trachs with outpatient dialysis
Trilogy Vent AVAPS (continuous)
Trilogy Vent AVAPS (intermittent)
Trilogy Vent BiPAP (intermittent)
Ventilator
Ventilator with onsite hemodialysis
Venturi Mask - Blue -FiO2 24% (Flow 2-4 LPM)
Venturi Mask - Green Adapter - FiO2 60% (Flow 12-15 LPM)
Venturi Mask - Red Adapter - FiO2 40% (Flow 10-12 LPM)
Venturi Mask - White Adapter - FiO2 28% (Flow 4-6 LPM)
Venturi Mask - Yellow Adapter - FiO2 35% (Flow 8-10 LPM)
SUD
Alcohol Abuse
Alcohol withdrawal management (CIWA-Ar)
Cretzfeld-Jakob Disease
History of overdose (>180 days)
History of overdose (91–180 days)
History of overdose (in last 90 days)
IV Drug Abuse
Medication Compliance Concerns
Outpatient Methadone Clinic Transport
Recent withdrawal episodes (31-60 days)
Recent withdrawal episodes (61-180 days)
Recent withdrawal episodes (in last 30 days)
Seizures/DTs (alcohol) (31-60 days)
Seizures/DTs (alcohol) (in last 30 days)
Unprescribed: Tox Screen + Amphetamines / Methamphetamines
Unprescribed: Tox Screen + Barbiturates
Unprescribed: Tox Screen + Benzodiazepines
Unprescribed: Tox Screen + Cannabinoids (THC)
Unprescribed: Tox Screen + Cocaine Metabolite
Unprescribed: Tox Screen + Methadone
Unprescribed: Tox Screen + Opiates
Unprescribed: Tox Screen + Oxycodone / Oxymorphone
Unprescribed: Tox Screen + Phencyclidine (PCP)
Saftey / Precautions
In-person sitter > 72 h
In-person sitter 24–48 h
In-person sitter 48–72 h
In-person sitter in last 24 h
Lap belts > 72 h
Lap belts 24–48 h
Lap belts 48–72 h
Lap belts in last 24 h
Mitts > 72 h
Mitts 24–48 h
Mitts 48–72 h
Mitts in last 24 h
Monitoring / Restraints d/t Altered / Transient Mental Status – Encephalopathy (e.g., hepatic, septic, metabolic)
Monitoring / Restraints d/t Altered / Transient Mental Status – Post-ictal state (after seizure)
Monitoring / Restraints d/t Altered / Transient Mental Status – Postoperative (e.g., anesthesia emergence)
Monitoring / Restraints d/t Altered / Transient Mental Status – Sedation or medication-related
Monitoring / Restraints d/t Dementia – Impulsive behavior (e.g., pulling tubes, resisting care)
Monitoring / Restraints d/t Dementia – Poor safety awareness (e.g., unsafe ambulation, unrecognized limitations)
Monitoring / Restraints d/t Dementia – Wandering / Elopement risk
Monitoring / Restraints d/t Equipment Interference – Persistent line/tube removal (not due to dementia, IDD, or TBI)
Monitoring / Restraints d/t IDD / TBI – Impulsive behavior (e.g., pulling at equipment, climbing out of bed)
Monitoring / Restraints d/t IDD / TBI – Poor safety awareness
Monitoring / Restraints d/t IDD / TBI – Wandering / Elopement risk
Monitoring / Restraints d/t Psychiatric – Aggressive or violent behavior toward others
Monitoring / Restraints d/t Psychiatric – Hallucinations / Delusions causing unsafe actions
Monitoring / Restraints d/t Psychiatric – Self-harming behaviors (non-suicidal)
Monitoring / Restraints d/t Psychiatric – Suicidal ideation or recent attempt
Posey bed > 72 h
Posey bed 24–48 h
Posey bed 48–72 h
Posey bed in last 24 h
Tele sitter > 72 h
Tele sitter 24–48 h
Tele sitter 48–72 h
Tele sitter in last 24 h
Wrist restraints > 72 h
Wrist restraints 24–48 h
Wrist restraints 48–72 h
Wrist restraints in last 24 h
Skin/Wounds
Advanced/Severe Arterial Ulcer
Autoimmune-related wounds
Clinitron Bed
Colostomies Ileostomies Urostomies
Dolphin Mattress
Early/Mild Arterial Ulcer
Fungal wounds
Hyperbaric Oxygen Therapy
Ischemic ulcers
Lymphedema Therapy
Mixed Venous-Arterial Ulcers
Neuro-ischemic ulcers
Neuropathic ulcers
Pressure Ulcers (Decubitus Ulcers) Deep Tissue Pressure Injury
Pressure Ulcers (Decubitus Ulcers) Stage 1
Pressure Ulcers (Decubitus Ulcers) Stage 2
Pressure Ulcers (Decubitus Ulcers) Stage 3
Pressure Ulcers (Decubitus Ulcers) Stage 4
Pressure Ulcers (Decubitus Ulcers) Unstageable
Progressing Arterial Ulcer
Radiation-induced wounds
Skin Graft Care
Surgical Wound-Irrigation & dressing
Third Degree Burns
Triden Bed
Venous Leg Ulcers
Wound Debridement
Wound Vacs
Surgery - Cardiopulmonary
J2700. Involving the heart or major blood vessels
J2710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords
J2799. Other major cardiopulmonary surgery
Surgery - Genitourinary
J2800. Involving genital systems
J2810. Involving the kidneys, ureters, adrenal glands, or bladder
J2899. Other major genitourinary surgery
Surgery - Major Joint
J2300. Knee Replacement
J2310. Hip Replacement
J2320. Ankle Replacement
J2330. Shoulder Replacement
Surgery - Neurological
J2600. Involving the brain, surrounding tissue or blood vessels
J2610. Involving the peripheral or autonomic nervous system
J2620. Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices
J2699. Other major neurological surgery
Surgery - Other Major
J2900. Involving tendons, ligaments, or muscles
J2910. Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, or spleen
J2920. Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus
J2930. Involving the breast
J2940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant
J5000. Other major surgery not listed above
Surgery - Other Orthopedic
J2500. Repair fractures of the shoulder or arm
J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle
J2520. Repair but not replace joints
J2530. Repair other bones (such as hand, foot, jaw)
J2599. Other major orthopedic surgery
Surgery - Spinal
J2400. Involving the spinal cord or major spinal nerves
J2410. Involving fusion of spinal bones
J2420. Involving Iamina, discs, or facets
J2499. Other major spinal surgery
