Fluid and electrolyte disorders

By Julie Shayne RN, CCDS, Peaks Region Clinical Documentation Integrity Educator

Documenting fluid and electrolyte disorders, when clinically significant, accurately supports the intensity of your service, severity of illness, risk of mortality, length of stay and risk adjustment metrics. Abnormal lab results of clinical significance must have an associated diagnosis documented by the treating physician. If the lab values are clinically significant (i.e., required clinical evaluation, therapeutic treatment, diagnostic studies, extended LOS, increased nursing care and/or monitoring), is there an associated diagnosis? For example:

• Acidosis (CC)

  • Lactic acidosis

  • Metabolic acidosis

• Metabolic alkalosis (CC)

• Hypomagnesium or hypermagnesemia

• Hypophosphatemia or hypophosphatemia

• Hypocalcemia and hypercalcemia

• Hypokalemia or hypokalemia

• Hyponatremia (CC) or hypernatremia (CC) or SIADH

• Hypovolemia

• Other electrolyte imbalance > specify

CC: Complications or Comorbidities — A secondary condition that reflects a greater severity of illness and complexity of patient care and can increase length of stay.

Case example: Three-day LOS medical case; impact w/o and with metabolic acidosis

Case example: Six-day LOS surgical case (colon resection); impact w/o and with hyponatremia

Remember, your CDI team is here to help and serve as a resource for your documentation needs to ensure an accurate clinical picture of the patient is reflected. Please email me at julie.shayne@imail.org with any questions.