2. Clinical Documentation Tip: Acute Encephalopathy
Hemlata Pun MSN, CCDS

3. Acute Encephalopathy
The National Institute of Neurological Disorders and Stroke (NINDS) describes encephalopathy as a term for “any diffuse disease of the brain that alters brain function or structure”
“Altered Mental Status” (AMS), is considered the Hallmark of encephalopathy
slides 4 thru 5 for more info

4. Acute Encephalopathy
It affects all aspects of brain (memory, communication, speech, behavior, orientation).
Typically presents as an acute onset and resolves when underlying cause is corrected.
Common causes: infection, fever, sepsis, dehydration, electrolytes imbalances, organ failure, hypoxia, toxins, drugs or poisoning.

5. Types of Encephalopathies
Metabolic: AMS caused by systemic metabolic disorders such as infection, fever, organ dysfunction, dehydration and electrolyte imbalance that is reversible.
Toxic: AMS caused by medications, illicit drugs, or toxic chemicals, that is reversible.
Septic: AMS manifestation of Severe Sepsis that is reversible.
Uremic: AMS associated with markedly elevated BUN as may be seen in Acute or Chronic Renal Failure.

6. Delirium vs. Encephalopathy
ICD-10 CM uses “Encephalopathy” to classify what DSM-V calls “delirium”
Encephalopathy is a medical term
Delirium is a psychiatric term

7. Clinical Example – “Mrs. Wilson”
HPI: 72 y/f, brought in from SNF, staff noted pt. delirious and increasingly confused x2days.
P/E: BP = 98/56 mmHg, T- 38.6C, AxO x1, foul smelling/cloudy urine
Lab: LE-3+, Protein-2+, WBC> 150,
Ucx -ecoli > 100,000
Rx: Ciprofloxacin, IVF’s

8. Documentation Impact UTI “Delirium” filler filler filler fillerfi
POOR
GOOD
UTI
“Delirium”
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Expected Length of Stay = 3 Days
E. coli-UTI
Metabolic Encephalopathy
Expected Length of Stay = 4 Days

9. Clinical Example – “Mr. Smith”
HPI: 57/y male found down by his daughter, difficult to arouse, with an open pill bottle on the night-stand
P/E: AMS, drowsy
Lab: Utox +opioids
Rx: Narcan

10. Documentation Impact Opioid Overdose Drug OD Toxic Encephalopathy
GOOD
POOR
Opioid Overdose
Toxic Encephalopathy
Expected Length of Stay = 4 Days
Drug OD
“AMS”
Expected Length of Stay = 2 Days

11. Key Points!
Use Diagnostic terms: Write “Metabolic encephalopathy” “Toxic Encephalopathy” (medical diagnosis)
Avoid Symptom terms: Avoid “AMS” “Delirium” (psychiatric term)
References:

12. THANK YOU ! ANY QUESTIONS ?