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: 7/7/03)