Category: Healthcare documentation

According to ICD-10-CM guidelines, a patient's resolved past conditions, including nutritional deficiencies, are documented using specific Z-codes, which provide crucial context for ongoing care. This detailed documentation influences a provider's understanding of a patient's overall health picture, even for issues that are no longer active.

According to a 2025 review, the prevalence of malnutrition among a study of older adults was 22.8%. Accurately documenting and knowing how should malnutrition that progresses in severity be coded is therefore crucial for capturing the patient's clinical picture and ensuring correct reimbursement.

According to research, fluid balance charts are a crucial, yet frequently poorly executed, aspect of patient documentation. To ensure accurate clinical assessment and prevent serious complications like dehydration or fluid overload, it is essential to know precisely what values would you record as part of your patients' fluid intake. This guide details the comprehensive list of sources and measurements to track.