M25.512 - Pain in left shoulder

Clinical Definition

Encephalopathy is a general term for brain dysfunction that can result from various causes including toxins, infections, metabolic disorders, or other medical conditions. It presents with altered mental status, confusion, cognitive decline, or changes in consciousness.

Documentation Requirements

• Specify type/cause:

  • Toxic

  • Metabolic

  • Hepatic

  • Hypertensive

  • Septic

  • Anoxic

• Document acuity:

  • Acute

  • Chronic

  • Acute on chronic

• Include clinical indicators:

  • Mental status changes

  • Glasgow Coma Scale scores

  • Laboratory findings

  • Imaging results

• Link to underlying condition if applicable

• Document severity (mild, moderate, severe)

Common Synonyms

• Brain dysfunction

• Altered mental status

• Brain fog

• Confusion

• Delirium (though technically different)

Coding Conflicts

Excludes1:

• Alcoholic encephalopathy

• Toxic encephalopathy due to drug abuse

Excludes2:

• Metabolic encephalopathy in neoplastic disease

• Wernicke's encephalopathy

Scribing.io Automation

Scribing.io's AI automatically:

• Identifies key terms indicating encephalopathy in clinical discussions

• Tags temporal indicators for acuity determination

• Links causative factors mentioned in the encounter

• Captures severity descriptors

• Flags associated symptoms and clinical findings

• Maps related lab values and imaging results to support the diagnosis

When dictating, simply mention "patient has [type] encephalopathy" along with supporting clinical evidence, and the AI will structure the documentation appropriately.