F43.10 - Post-traumatic stress disorder, unspecified

Clinical Definition

Nausea is a subjective sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. When documented with vomiting, it indicates the patient both feels nauseated and has experienced actual episodes of emesis.

Documentation Requirements

• Temporal factors:

  • Acute vs. chronic

  • Duration of symptoms

• Associated conditions:

  • Pregnancy status

  • Post-procedural relation

  • Underlying cause if known

• Severity indicators:

  • Frequency of vomiting episodes

  • Impact on hydration status

  • Ability to tolerate oral intake

• Treatment response:

  • Antiemetic effectiveness

  • Need for IV hydration

Common Synonyms

• "Sick to stomach"

• "Queasy"

• "Upset stomach"

• "Throwing up"

• "Getting sick"

• "Dry heaves" (without vomiting)

Coding Conflicts

Excludes1:

• Motion sickness (T75.3)

• Morning sickness in pregnancy (O21.-)

• Psychogenic vomiting (F50.8)

Excludes2:

• Hyperemesis gravidarum (O21.0)

• Bilious vomiting (R11.14)

Scribing.io Automation

The AI scribe automatically identifies:

• Direct mentions of nausea/vomiting

• Temporal language indicating duration

• Associated symptoms like dehydration

• Treatment responses

• Quantified episodes (e.g., "vomited 3 times today")

• Qualifying terms indicating severity

Structured documentation is auto-generated with proper specificity for billing requirements.