Assess the hematologic status in the context of the skilled reason and document the judgment:
Relevant counts and their trend (hemoglobin/hematocrit, platelets, white count/absolute neutrophil count) and the symptoms of anemia (fatigue, dyspnea, tachycardia, pallor).
For thrombocytopenia: bleeding signs (bruising, petechiae, gum/nose bleeding, hematuria, melena) and bleeding precautions; for neutropenia: infection signs and neutropenic precautions, remembering fever may be the only sign.
For a transfusion: the order and consent, the pre-transfusion vitals and identity check, and intra-/post-transfusion monitoring for a reaction.
MDS-supportive data
Transfusion and isolation are coded in MDS Section O0110, relevant medications in Section N, and the hematologic diagnosis in Section I. The record must document the counts/trend, the transfusion and its monitoring, and the precautions so the MDS is supported.
