Clinical documentation Tip: Renal Status

This month’s “hot topic” from clinical documentation is renal status.  Acute renal insufficiency does not capture your patient’s severity of illness.  Renal insufficiency typically refers only to mild kidney dysfunction.  Renal insufficiency and A/CKD are not synonymous with Acute Kidney Injury or Failure; please do not use these terms interchangeably.

Acute Kidney Injury does capture your patient’s severity of illness.  Acute Kidney Injury is defined as a rapid loss of kidney function usually within 48 hours, with a rise in serum creatine. (Absolute increase of greater than or equal to 0.3 mg/dl or percentage increase of greater than or equal to 50% or, based on a rapid reduction in urinary output, typically defined as less than 0.5 ml/kg/hr for more than 6 hours.) Typical causes of Acute Kidney Injury include prerenal, intrinsic and post-renal etiologies.
Please specify your meaning of acute on chronic kidney disease. Do you simply mean this patient has chronic kidney disease?  If your patient does indeed have chronic kidney disease, it is important that you specify the stage.

Stages of chronic kidney disease (As stated by the National Kidney Foundation)
1. Kidney damage with normal or increased GFR > 90
2. Kidney damage with mild decrease in GFR 60-89
3. Moderate decrease in GFR 30-59
4. Severe decreases in GFR 15-29
5. Kidney failure < 15 or dialysis

We appreciate all of you who have been answering our queries. Together we can work to increase our patients’ severity of illness so that it may accurately reflect our patients’ conditions and the great care we provide.