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Dehydration [Documentation Suggestions]
List any history of inadequate fluid intake, diuretic therapy, or nausea and/or vomiting.
Describe clinical signs and symptoms (e.g., orthostatic tachycardia, postural hypotension, poor skin turgor, elevated urine osmolality, etc.).
If known, list dehydration’s underlying cause and whether cause required acute treatment (e.g., vomiting with IM antiemetic, UTI with IV antibiotic, etc.).
Additional notes:
Source
: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site:
http://www.hce.org/medicare/mcareHPMP.html
7/7/03)