From the Research
The ICD-10 code for poor fluid intake is R63.6, which represents "Insufficient intake of food and water." This code falls under the category of symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified. When documenting poor fluid intake in a medical record, this is the appropriate code to use, as noted in general medical practice 1. It's essential to note that this code specifically addresses the symptom of inadequate fluid consumption rather than any underlying cause.
In clinical practice, you should also document any associated conditions that may be contributing to the poor fluid intake, such as dysphagia (difficulty swallowing), altered mental status, or physical inability to obtain fluids. These underlying conditions would require additional, separate ICD-10 codes. Proper documentation of poor fluid intake is essential for monitoring patients at risk for dehydration and ensuring appropriate interventions are implemented, which can impact morbidity, mortality, and quality of life 2, 3.
Some key considerations in managing patients with poor fluid intake include:
- Monitoring for signs of dehydration and malnutrition 2
- Assessing the need for enteral or parenteral nutrition 4, 5
- Implementing strategies to improve fluid intake, such as oral supplements or tube feeding 1
- Regularly reviewing and adjusting the patient's nutrition and hydration plan to ensure their individual needs are being met 2, 1
By prioritizing accurate documentation and appropriate management of poor fluid intake, healthcare providers can help reduce the risk of complications and improve patient outcomes, ultimately enhancing quality of life and reducing morbidity and mortality.