Clinical Documentation Tip Acute Encephalopathy Hemlata Pun MSN

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Clinical Documentation Tip: Acute Encephalopathy Hemlata Pun MSN, CCDS

Clinical Documentation Tip: Acute Encephalopathy Hemlata Pun MSN, CCDS

Acute Encephalopathy • The National Institute of Neurological Disorders and Stroke (NINDS) describes encephalopathy

Acute Encephalopathy • The National Institute of Neurological Disorders and Stroke (NINDS) describes encephalopathy as a term for “any diffuse disease of the brain that alters brain function or structure” www. acphospitalist. org • “Altered Mental Status” (AMS), is considered the Hallmark of encephalopathy • slides 4 thru 5 for more info

Acute Encephalopathy • It affects all aspects of brain (memory, communication, speech, behavior, orientation).

Acute Encephalopathy • It affects all aspects of brain (memory, communication, speech, behavior, orientation). www. acphospitalist. org • Typically presents as an acute onset and resolves when underlying cause is corrected. • Common causes: infection, fever, sepsis, dehydration, electrolytes imbalances, organ failure, hypoxia, toxins, drugs or poisoning.

Types of Encephalopathies • Metabolic: AMS caused by systemic metabolic disorders such as infection,

Types of Encephalopathies • Metabolic: AMS caused by systemic metabolic disorders such as infection, fever, organ dysfunction, dehydration and electrolyte imbalance that is reversible. • Toxic: AMS caused by medications, illicit drugs, or toxic chemicals, that is reversible. • Septic: AMS manifestation of Severe Sepsis that is reversible. • Uremic: AMS associated with markedly elevated BUN as may be seen in Acute or Chronic Renal Failure.

Delirium vs. Encephalopathy • ICD-10 CM uses “Encephalopathy” to classify what DSM-V calls “delirium”

Delirium vs. Encephalopathy • ICD-10 CM uses “Encephalopathy” to classify what DSM-V calls “delirium” • Encephalopathy is a medical term • Delirium is a psychiatric term

Clinical Example – “Mrs. Wilson” • HPI: 72 y/f, brought in from SNF, staff

Clinical Example – “Mrs. Wilson” • HPI: 72 y/f, brought in from SNF, staff noted pt. delirious and increasingly confused x 2 days. • P/E: BP = 98/56 mm. Hg, T- 38. 6 C, Ax. O x 1, foul smelling/cloudy urine • Lab: LE-3+, Protein-2+, WBC> 150, Ucx -ecoli > 100, 000 • Rx: Ciprofloxacin, IVF’s

Documentation Impact POOR • UTI • “Delirium” • fillerfi Expected Length of Stay =

Documentation Impact POOR • UTI • “Delirium” • fillerfi Expected Length of Stay = 3 Days GOOD • E. coli-UTI • Metabolic Encephalopathy Expected Length of Stay = 4 Days

Clinical Example – “Mr. Smith” • HPI: 57/y male found down by his daughter,

Clinical Example – “Mr. Smith” • HPI: 57/y male found down by his daughter, difficult to arouse, with an open pill bottle on the night-stand • P/E: AMS, drowsy • Lab: Utox +opioids • Rx: Narcan

Documentation Impact POOR GOOD • Drug OD • “AMS” • Opioid Overdose • Toxic

Documentation Impact POOR GOOD • Drug OD • “AMS” • Opioid Overdose • Toxic Encephalopathy Expected Length of Stay = 2 Days Expected Length of Stay = 4 Days

Key Points! • Use Diagnostic terms: Write “Metabolic encephalopathy” “Toxic Encephalopathy” (medical diagnosis) •

Key Points! • Use Diagnostic terms: Write “Metabolic encephalopathy” “Toxic Encephalopathy” (medical diagnosis) • Avoid Symptom terms: Avoid “AMS” “Delirium” (psychiatric term) References: https: //www. acphospitalist. org/archives/2015/01/coding. htm https: //emedicine. medscape. com/article/1135651 -overview#a 5 https: //www. medicinenet. com/encephalopathy/article. htm

THANK YOU ! ANY QUESTIONS ?

THANK YOU ! ANY QUESTIONS ?

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