Nutritional & Misc Metabolic Disorders

Diagnosis: Nutritional & Misc Metabolic Disorders

Applicable for MSDRGs:  640, 641

MD documentation should address:

1. Presenting symptoms: inadequate po intake; postural BP changes; excessive urination, hunger or thirst; AMS; blurred vision; drowsiness, parasthesias or profound lethargy/malaise; weight loss or obesity with BMI; poor skin turgor; quality of respirations; breath odor
2. X-Ray Findings: evidence of cystic fibrosis
3. EKG: new findings and subsequent changes – relation to abnormal electrolytes; indication of myocardial ischemia/infarction
4. O2 sat/ABG findings: acidosis/alkalosis; pH; hypoxemia
5. Lab values: evidence of hypoglycemia; malnutrition; other nutritional deficiencies; disorders of magnesium & calcium metabolism; cystic fibrosis; electrolyte disorders (DO NOT USE ARROWS)
6. Coma: with ketoacidosis; hyperosmolar; nonketotic; insulin; hypoglycemic; hepatic
7. Renal failure (acute, chronic or acute on chronic, ATN) and any relationship between RF and pulm edema
8. Evidence of encephalopathy and cause if known (metabolic, specific organ dysfunction)
9. Treatment with medications, procedures or therapies

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