COVID-19
Overview
SARS-CoV-2 is the virus that causes COVID-19
Clinical criteria for diagnosis include:
At least two: fever, chills, rigors, myalgia, headache, sore throat, difficulty breathing, new loss of taste/smell
At least one: cough, shortness of breath, difficulty breathing
Severe respiratory illness with pneumonia or acute respiratory distress syndrome (ARDS).
Detection of RNA virus via amplification is confirmatory evidence, while detection of specific antigen or antibody is presumptive evidence.
Epidemiologic linkage:
Close contact with confirmed/probably case of COVID-19 disease
Close contact with a person with compatible illness AND COVID-19 case linkage
Travel to or residence in an area with sustained community COVID-19 transmission
Member of a risk cohort as defined by public health authorities during an outbreak.
Tips for Documenting COVID-19
Confirmatory COVID-19 testing should be documented in the chart
Confirmatory testing not performed at DCMC must be obtained for patient’s DCMC record.
Document all associated conditions as “due to COVID-19”
If testing inconclusive or still pending upon discharge, write “presumptive positive” if the patient is undergoing management for COVID-19
A “probable” diagnosis:
Meets clinical criteria AND epidemiologic evidence with no confirmatory laboratory testing performed for COVID-19.
Meets presumptive laboratory evidence AND either clinical criteria OR epidemiologic evidence.
MIS-C
Multisystem inflammatory syndrome in children (MIS-C) is a condition where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs. Children with MIS-C may have fever and various symptoms, including abdominal pain, vomiting, diarrhea, neck pain, rash, conjunctivitis, or fatigue, and in severe cases, hypotension and shock. The cause of MIS-C is unknown, however, if testing clearly demonstrates COVID-19 positivity, this should be included and linked with MIS-C.