Renal Failure

Diagnosis: Renal Failure

Applicable for MSDRGs: 682, 683, 684

MD documentation should address:

1. Presenting symptoms: AMS; fever or hypothermia; nausea and/or vomiting + frequency; dialysis pt; SNF or home health pt; indwelling urinary catheter; recent urine output; recent fluid intake
2. CXR findings (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. Radiologic Findings: evidence of renal function status
4. EKG: new findings and subsequent changes
5. Lab values: BUN, Creatine and GFR if possible; U/A findings (i.e. hematuria, bacteria, etc)
6. 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
7. Renal failure as acute; chronic; or acute-on-chronic
8. ARF: severity or location of lesion; cause of failure
9. CRF: specify CKD stage I-V or ESRD; cause of failure
10. **Specify Failure or Insufficiency (not the same condition)**
11. Evidence of HTN and/or Heart Disease; and relationship with Renal Failure
12. Evidence of dehydration and cause if known
13. Evidence of encephalopathy and cause if known (metabolic, specific organ dysfunction)
14. Treatment with medications, procedures or therapies

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