Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.
Electrolyte imbalances are almost invariably present in the hospitalized patient. They arise from poor oral intake, abnormal renal function, low blood pressure, urinary losses or gastrointestinal losses. Newer and updated forms of coding will require more detail and more specificity, even for the documentation of electrolyte imbalances. Conditions such as hyponatremia, hypokalemia, hypernatremia, hyperkalemia and also calcium magnesium and phosphate abnormalities will increase the severity of illness and risk of mortality of the cases. Diagnosing them, elaborating a plan of care and finally documenting all the findings is what is needed in order for the conditions to be coded properly and to comply with medical necessity requirements.
Marco A. Ramos MD, CCDS