Query Compliance
Provider documented “Patient has been somewhat hypotensive and I have therefore given her a 500cc bolus of IV fluids.” Diagnosis on order for IV bolus is hypotension.
Query stated: Clinical findings: Sodium 129, 133, 129, 131 Treatment: 0.9% NaCl 500 ml IV bolus, lab monitoring.
My question - since provider clearly documented intent of IV bolus treatment to be for hypotension, is it appropriate to note this treatment in a query for hyponatremia when it was not administered to treat low sodium levels?
Paula Vuksinic
Comments
Good morning,
Because the NaCl bolus is documented as being given for hypotension, and hyponatremia can be clinically significant, the query could note the normal saline was given for hypotension, offer the lab values and ask if the clinical findings are clinically significant and if so to add an associated diagnosis and treatment.
Lori