Assess fluid and electrolyte status and document the skilled judgment:
Intake and output against the ordered parameters and the fluid balance; weight trend as a volume marker; and mucous membranes, skin turgor, and blood pressure/heart rate (including orthostatic change).
For IV fluids: the ordered fluid and rate, the site, the response, and any sign of over-hydration (edema, crackles, dyspnea) especially in HF/renal residents.
Contributing factors (fever, diarrhea/vomiting, reduced intake, diuretics) and relevant electrolytes/renal function from labs; signs of dehydration-related delirium or hypotension.
MDS-supportive data
Parenteral/IV fluids are coded in MDS Section K0510; dehydration/fluid signs in Section J; the diagnosis in Section I. The record must document the fluid administration, the intake/output/weight, and the fluid status so the MDS is supported.
