Clinical Documentation Tip Sheets

Nephrology

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).

RENAL FAILURE

CHRONIC KIDNEY DISEASE

> Renal failure without acuity/chronicity codes to unspecified > Acute renal failure and acute kidney injury code to the same code

> Stage : Stage 1 (GFR: >90), Stage 2 (GFR: 60-89), Stage 3a (GFR: 45- 59), Stage 3b (GFR: 30-44), Stage 4: (GFR: 15-29), Stage 5 (GFR: <15), ESRD (any stage with regular dialysis).

>Tip : Document if the patient is dialysis dependent.

> Chronic renal failure codes to chronic kidney disease

> Renal insufficiency codes to a non-specific code

ACUTE KIDNEY INJURY

ACUTE TUBULAR NECROSIS >Definition: Rapid rise in serum creatinine with one of the following: urine sodium >40, FENA >2%, muddy casts in urinalysis >Tip: Contract induced nephropathy doesn’t code to ATN, consider adding ATN as well.

> Definition: Increase in creatinine level to ≥ 1.5x baseline within 7 days OR Increase (not decrease) in creatinine of ≥ 0.3 mg/dL within 48 hours OR Urine output < 0.5 ml/kg/hr for 6 hours

> Stage: Stage 1 (Cr increase: 1.5x), Stage 2 (Cr increase: 2x), Stage 3 (Cr increase: 3x)

RHABDOMYOLYSIS > Type: traumatic, non traumatic: metabolic, inflammatory, ischemic > Document: associated AKI, ATN, electrolyte imbalance

HEPATORENAL SYNDROME > Definition: Acute kidney injury due to acute or chronic liver disease. It is characterized by a progressive rise in creatinine in patients with liver disease (not due to another cause).

ELECTROLYTE DISORDERS

ACID/BASE DISORDERS

>Acuity: Acute, chronic

>Acuity: Acute, chronic

> Specify: the acid/base disorder, e.g., metabolic acidosis

> Specify: the electrolyte abnormality, e.g., hyponatremia

> Document: treatment/evaluation/monitoring performed

> Document: treatment/evaluation/monitoring performed, e.g., hyponatremia NA 131 monitor or hyponatremia NA 125 hypertonic saline ordered or hyponatremia NA 130 hold diuretics.

> Tip: Add the clinical significance of ABG findings to your notes