Diabetes Mellitus

Diagnosis: Diabetes Mellitus

Applicable for MSDRGs: 637, 638, 639

MD documentation should address:

1. Presenting symptoms: postural BP changes; excessive urination, hunger or thirst; AMS; blurred vision; drowsiness, parasthesias or profound lethargy/malaise; weight loss or obesity with BMI; dehydration; quality of respirations; breath odor
2. EKG: new findings and subsequent changes – relation to abnormal electrolytes; indication of myocardial ischemia/infarction
3. O2 Sat or ABG Findings (acidosis/alkalosis; pH; hypoxemia if present)
4. Lab values: Blood glucose and hemoglobin A1C; U/A (specific gravity, signs of infection, any ketones,  glucose  or protein); electrolyte abnormalities (DO NOT USE ARROWS)
5. Specify if diabetes is secondary rather than “primary”
6. Primary diabetes: type I or type II; controlled or uncontrolled; with complications (ketoacidosis, hyperosmolarity, coma, renal, ophthalmic, neurological, peripheral circulation, other)
7. Secondary diabetes: type I or type II; controlled or uncontrolled; with complications (ketoacidosis, hyperosmolarity, coma, renal, ophthalmic, neurological, peripheral circulation, other)
8. Conditions possibly related to DM: HTN (benign, malignant or accelerated); CV; hyperlipidemia; tobacco or ETOH use
9. Renal failure (acute, chronic or acute on chronic, ATN) and any relationship between RF and DM
10. Treatment with medications, procedures or therapies

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