Kidney/Urinary Tract Infection

Diagnosis: Kidney/Urinary Tract Infection

Applicable for MSDRGs: 689, 690

MD documentation should address:

1. Presenting symptoms: abd pain; fever or hypothermia; vomiting w/ frequency and appearance; SNF or home health pt; outpt tx including meds; indwelling urinary catheter
2. CXR findings (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. Radiologic Findings: evidence of kidney infection or UTI
4. EKG: new findings and subsequent changes
5. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure)
6. Lab values: U/A, Cultures for presence of UTI
7. Evidence of SIRS: Must have at least 2 of the following:
   • Tachycardia: Pulse>90
   • Tachypnea: RR >20
   • Temp >100.4 (38C) or <96.8 (36C)
   • WBC >12,000 or <4,000 or >10% bands
8. Site of infection if known (nephritis, pyelonephritis, cystitis)
9. Infection as acute or chronic if known
10. Relationship of infection to implanted device or procedure
11. Treatment with medications or antibiotics, even if organism is presumed
12. Evidence of Dehydration and cause if known
13. Evidence of encephalopathy and cause if known (metabolic, specific organ dysfunction)

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