Quality and Population Health

Improving Documentation of Major Comorbid Conditions: Encephalopathy

As a follow up to Quality Update: Key Feature of Wave 3 Helps Providers Improve Documentation of Major Comorbid Conditions, let’s review encephalopathy.

Encephalopathy is any diffuse disease of the brain that alters brain function or structure. It can be acute or chronic.

Acute encephalopathy is reversible and resolves when the underlying cause is corrected. It needs to be further specified as to one of the following:

  • Metabolic: can be due to fever, dehydration, electrolyte imbalance, hypoglycemia, hypoxemia, infection and organ failure.
  • Toxic: refers to the effects of drugs or toxins.
  • Toxic-metabolic: suggests a combination of toxic and metabolic factors.
  • Septic encephalopathy: represents a manifestation of severe sepsis.
  • Hepatic encephalopathy: neurologic impairment with end-stage liver disease.

Chronic encephalopathy is structural and irreversible due to permanent brain damage.

Specificity is the key to improving documentation, which will positively reflect each patient’s severity of illness and risk of mortality.