Obesity, Malnutrition, Alcohol, Tobacco and Substance

Obesity

 

• Obesity
    --Morbid (severe)
    --Due to excess calories
    --With alveolar hypoventilation (Pickwickian syndrome)
    --Drug Induced
    --Document drug
    --Other
    --Due to excess calories, familial, endocrine
• Overweight
• Body Mass Index (BMI)
• Document any associated diagnoses/conditions

Malnutrition

• Severity:
    --Mild (first degree)
    --Moderate (second degree)
    --Severe (third degree)
• Avoid documenting a range of severity, such as “moderate to severe”
• Form:
    --Kwashiorkor (rarely seen in the U.S.)
    --Marasmus
    --Marasmic kwashiorkor
    --Other
• Document any associated diagnoses/conditions

Alcohol, Tobacco, and Substance Use

• Identify the specific type of drug or substance
• Describe the frequency of usage as:
    --Use
    --Abuse
    --Dependence
    --In remission
• Describe mode of nicotine use as cigarettes, chewing tobacco, pipe,
and/or gum
• Specify intoxication/withdrawal as “Uncomplicated” or “With delirium”
• Document any withdrawal symptoms
• Document any associated diagnoses/conditions
• List the blood alcohol level, if available
• State “no related complications,” when applicable
• Document any related mood disorder
• Document any delusions, hallucinations, anxiety, sleep disorders, sexual
dysfunctions, or other related conditions
• List any treatment provided:
    --Detoxification services
    --Counseling
    --Psychotherapy
    --Medication management