Electrolyte imbalances are almost invariably present in the hospitalized patient. They arise from poor oral intake, abnormal renal function, low blood pressure, urinary losses or gastrointestinal losses. Newer and updated forms of coding will require more detail and more specificity, even for the documentation of electrolyte imbalances. Conditions such as hyponatremia, hypokalemia, hypernatremia, hyperkalemia and also calcium magnesium and phosphate abnormalities will increase the severity of illness and risk of mortality of the cases. Diagnosing them, elaborating a plan of care and finally documenting all the findings is what is needed in order for the conditions to be coded properly and to comply with medical necessity requirements.

Marco A. Ramos MD, CCDS

In order to quote from this article please use the following:

Marco A. Ramos, “Clinical Documentation Improvement Series #5, Documenting Electrolyte Imbalances,” SMO Blog (blog), August 20, 2018, https://steemit.com/health/@secondmedicalop/clinical-documentation-improvement-series-5-documenting-electrolyte-imbalances

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure

- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)

- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?

- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies