This is my nephrology provider's portion of the split-share assessment/plan on an in-patient hospital progress note. Based on his documentation how would you level this and why? I've been especially struggling with defining what constitutes a high level of risk and how specific the provider needs to be.
"I am seeing him in follow-up for acute on chronic kidney disease. I reviewed her labs today. Kidney function has not gotten worse significantly. With good diuresis I expect the blood pressure to improve. If patient is post metastatic then will add sodium bicarb supplement. Will continue to monitor kidney function closely to make next recommendations."
Here's another example of his documentation. This is an initial in-patient hospital visit.
"I was consulted for renal failure and hyperkalemia. Patient was brought to the ER with complaints of shortness of breath and lower extremity swelling. Because of her respiratory failure she was put on BiPAP and admitted to ICU. As she was thought to be in CHF exacerbation she ended up getting IV diuretic. As patient's potassium was high she ended up getting calcium chloride insulin and D50. Patient has acute kidney injury secondary to decreased renal perfusion. Will check urine studies. Will put her on normal saline at 75 mil per hour. Discussed care with intensivist. Will repeat the potassium and if it is still high we will treat with calcium gluconate insulin and D50. For her UTI please dose antibiotic based on the creatinine clearance. I reviewed her labs from yesterday and also today. Will continue to monitor kidney function closely to make next recommendations."
Thank you for any help!
"I am seeing him in follow-up for acute on chronic kidney disease. I reviewed her labs today. Kidney function has not gotten worse significantly. With good diuresis I expect the blood pressure to improve. If patient is post metastatic then will add sodium bicarb supplement. Will continue to monitor kidney function closely to make next recommendations."
Here's another example of his documentation. This is an initial in-patient hospital visit.
"I was consulted for renal failure and hyperkalemia. Patient was brought to the ER with complaints of shortness of breath and lower extremity swelling. Because of her respiratory failure she was put on BiPAP and admitted to ICU. As she was thought to be in CHF exacerbation she ended up getting IV diuretic. As patient's potassium was high she ended up getting calcium chloride insulin and D50. Patient has acute kidney injury secondary to decreased renal perfusion. Will check urine studies. Will put her on normal saline at 75 mil per hour. Discussed care with intensivist. Will repeat the potassium and if it is still high we will treat with calcium gluconate insulin and D50. For her UTI please dose antibiotic based on the creatinine clearance. I reviewed her labs from yesterday and also today. Will continue to monitor kidney function closely to make next recommendations."
Thank you for any help!