Clinical Documentation Tip Sheets

ANTIDIURETIC HORMONE (ADH) DISORDERS

Diabetes Insipidus (Low ADH) > Cause: Pituitary gland damage/resection, hypothalamus damage drugs, infection, etc.

Syndrome of Inappropriate Antidiuretic Hormone (High ADH): > Cause : include CNS disorders like stroke, hemorrhage, infection, trauma; neoplasm; drugs; lung disease (especially pneumonia); HIV; hypothyroidism.

PITUITARY GLAND DISORDERS

> Overproduction effect: e.g., Acromegaly, galactorrhea, Cushing's disease, SIADH > Underproduction effect: e.g., hypothyroidism, hypogonadism, adrenocortical insufficiency, diabetes insipidus Tip: document every component of hormone imbalance associated with pituitary gland disorders

THYROID GLAND DISORDERS

> Type: hypothyroidism, hyperthyroidism > Cause: Grave’s disease, thyroidectomy, Hashimoto’s > Associated conditions: myxedema, cardiac arrhythmias, Grave’s ophthalmopathy, osteoporosis, etc.

METABOLIC SYNDROME

> Document: with 3 of: DM, HTN, HLD, Obesity

HYPOGLYCEMIA

Inpatient admission is indicated for 1 or more of the following: Altered mental status that is severe or persistent Neurologic findings (eg, seizure, ataxia, dysphasia, focal deficit) that are recurrent or persist despite observation care Other significant clinical signs or symptoms of hypoglycemia that do not resolve despite observation care Persistent or recurrent hypoglycemia despite observation care Prolonged monitoring for recurrent hypoglycemia (beyond observation care)

HHS Hyperglycemic hyperosmolar state, as indicated by ALL of the following:

Plasma glucose greater than 600 mg/dL (33.3 mmol/L) Serum osmolality greater than 320 mOsm/kg (mmol/kg)[J] Neurologic dysfunction (eg, stupor, coma, seizure) Arterial or venous pH greater than 7.30[I] Serum bicarbonate greater than 18 mEq/L (mmol/L