Clinical Documentation Tip Sheets

Endocrinology

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

DIABETES

> Type: 1, 2, secondary, gestational

> Associated conditions: neuropathy, nephropathy, retinopathy, angiopathy, gastroparesis, PVD, ulcers, osteomyelitis

Tip: with diabetic foot ulcers also document the cause of the ulcer; diabetic PVD or diabetic neuropathy or both.

DIABETIC HYPERGLYCEMIA HYPEROSMOLAR STATE (HHS): Characterized by severe hyperglycemia, hyperosmolarity and dehydration without significant ketoacidosis, and usually some alteration in consciousness (coma if severe). HHS almost never occurs in Type 1 DM. Diagnostic criteria include: Blood sugar > 600mg/dl Serum osmolality > 320 mmol/L Exclusion of DKA: pH > 7.30, Bicarbonate > 18, absence of significantly elevated serum ketones

DIABETIC KETOACIDOSIS (DKA)

Characterized by hyperglycemia, acidosis, elevated serum ketones, and dehydration. Occurs primarily in Type 1 DM patients but can occur in Type 2. Diagnostic criteria require ALL of the following:

Blood sugar > 250 mg/dl Acidosis with pH < 7.30 Bicarbonate < 18 mEq/L (CO2/HCO3 on BMP or ABG)

Inpatient admission is indicated for 1 or more of the following: Hyperglycemia (plasma glucose greater than 250 mg/dL or less than 250 with pregnancy and chronic renal/liver disease. Ketonuria or ketonemia (eg, serum beta hydroxybutyrate 3.8 mmol/L or higher, or moderate to large ketonuria) Acidosis (eg, anion gap greater than 10 (or above the upper limit of normal for laboratory), pH 7.30 or less, or serum bicarbonate 18 mEq/L (mmol/L) or less)

Inpatient admission is indicated for 1 or more of the following: Metabolic acidosis (eg, anion gap greater than 10 (or above the upper limit of normal for local laboratory), or arterial or venous pH 7.30 or less) that recurs or persists despite observation care

Hypotension (See cardiovascular) Arterial or venous pH less than 7.0

Serum bicarbonate less than 10 mEq/L (mmol/L) Altered mental status that is severe or persistent Rise in creatinine to 2 times its baseline value or higher (ie, reduction of more than 50% in estimated glomerular filtration rate) Dehydration that persists despite observation care