Poisoning and Toxic Effects of Drugs

Diagnosis: Poisoning and Toxic Effects of Drugs

Applicable for MSDRGs: 917, 918

MD documentation should address:

1. Presenting symptoms: any sign or symptom that could be an adverse effect of drugs, other medicinal or biological substances or nonmedicinal substances; hx of aspiration or smoke inhalation; cardiac arrythmias; chronic cardiac or pulm disorder
2. CXR findings: (i.e. pulmonary edema, CHF, pleural effusions, emphysema, atelectasis /infiltates and elevated hemidiaphragms) and relation to adverse effect of ingestion or exposure to drug or other substance
3. EKG: new findings and subsequent changes and relation to adverse effect of drugs or other substances
4. O2 Sat or ABG Findings: hypoxia; acute/chronic/acute-on-chronic respiratory failure; hypo- or hypercapnia; acidosis or alkalosis
5. Lab values: evidence of adverse effects of drugs or other substances
6. **Document whether the external cause of the adverse effect was: accidental poisoning; in therapeutic use; a suicide attempt; an assault; or undetermined**
7. Accidental poisoning: accidental overdose of drug; wrong substance given or taken; drug taken inadvertently; accident involving use of drugs and biologicals in procedures; Rx drug taken with ETOH or non-RX drug
8. Therapeutic Use: correct drug or substance properly administered in proper dosage
9. Suicide Attempt: self-inflicted poisoning or injury involving drugs or other substances
10. Assault: poisoning or injury inflicted by another person to harm
11. Undetermined: accidental or intentional poisoning or injury cannot be determined
12. **Document drugs and/or substances which caused the adverse effect**
13. Evidence of SIRS: Must have at least 2 of the following:
    • Tachycardia: Pulse>90
    • Tachypnea: RR >20
    • Temp >100.4 (38C) or <96.8 (36C)
    • WBC >12,000 or <4,000 or >10% bands
14. Evidence of specific organ involvement
15. Treatment with medications, procedures or therapies

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