Documentation Guidelines

• Physical findings of hormone excesses or deficiencies: Decreased body hair, hirsutism, altered secondary sexual characteristics, acromegaly, galactorrhea; vital signs; neurological assessment; visual examination

• Response to therapy: Surgery, radiation, medications, counseling

• Postoperative management: CSF drainage, nasal packing, wound drainage, signs of complications (diabetes insipidus, infection, increased intracranial pressure, hemorrhage, CSF leak, airway compromise)

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