R07.9 - Chest pain, unspecified

Clinical Definition

Nausea and vomiting are symptoms where the patient feels sick to their stomach (nausea) and/or expels stomach contents through the mouth (vomiting). When persistent and severe, these symptoms can be classified as non-infectious gastroenteritis.

Documentation Requirements

• Duration of symptoms (acute vs chronic)

• Frequency of episodes

• Presence of both nausea AND vomiting must be explicitly documented

• Any associated dehydration (mild, moderate, severe)

• Underlying cause if known

• Rule out/documentation of:

  • Pregnancy status

  • Infectious causes

  • Food poisoning

  • Other systemic conditions

Common Synonyms

• "Upset stomach"

• "Throwing up"

• "Sick to stomach"

• "Getting sick"

• "Queasy"

Coding Conflicts

Excludes1:

• Vomiting due to gastrointestinal infection

• Morning sickness/hyperemesis gravidarum

• Food poisoning

• Motion sickness

Excludes2:

• Functional vomiting

• Cyclical vomiting syndrome

Scribing.io Automation

The AI scribe automatically identifies:

• Temporal markers for duration

• Frequency descriptors

• Associated symptoms

• Severity indicators

• Negative findings ruling out excluded conditions

• Dehydration status

The system alerts providers when documentation is insufficient to support the specific code, particularly when duration or frequency details are missing.