Clinical Documentation Tip Electrolyte Abnormalities Freddy Santoso CCS

Clinical Documentation Tip: Electrolyte Abnormalities Freddy Santoso, CCS, CCDS

Penny For Your Thoughts … “Low Na” • Hyponatremia • SIADH • Cerebral Salt Wasting • Hyperosmolar State • Pseudohyponatremia

Clinical Example – “Mrs. Smith” • HPI: 61 y female with h/o nausea, vomiting, poor PO intake x 1 week, presents with near syncopal episode • P/E: BP = 99/52 mm Hg, HR = 110, dry mucous membranes • Lab: Cr 2. 1 from baseline 1. 0, Na 126 • Rx: IV NS Boluses

Documentation Impact POOR GOOD • AKI • “low Na” • fillerfi • AKI • Hyponatremia Expected Length of Stay = 2 Days Expected Length of Stay = 3 Days

Clinical Example – “Mr. Smith” • HPI: 55 y homeless male with h/o binge drinking brought in after being found down. • P/E: HR 120/min, BP = 162/97, diaphoretic, confused, tremulous, cachectic • Lab: On day 3, Mg 0. 5, K 3. 1, Phos 1. 8, Ca 7. 0, albumin 1. 9 • Rx: Mg, K, Ca, Phos repletion

Documentation Impact POOR GOOD • Alcohol Withdrawal • “Refeeding syndrome – Phosphate, Ca, K, and Mag repleted” • Alcohol Withdrawal • Hypophosphatemia/ Hypocalcemia/ Hypomagnesemia/ Hypokalemia • Severe Malnutrition Expected Length of Stay = 3 Days Expected Length of Stay = 5 Days

Key Points • Use diagnostic terms (DO write out “hypomagnesemia”) • Specify clinical significance of lab findings (avoid “low Mg”) • Indicate reason for initiation of Rx (don’t just write “start mag sulfate”)

THANK YOU ! ANY QUESTIONS ?