Clinical Documentation Tip Sheets

RESPIRATORY FAILURE

> Acute: Document each of the following: 1. Respiratory distress: (eg, tachypnea, use of accessory respiratory muscles) 2. O2 requirement : ≥4L O2 required to maintain saturation of 92% for ≥2 hours OR ≥2L of O2 required for >24 hours 3. Hypoxia or hypoxemia: PaO2 <60 mm Hg on room air OR PaO2 /FiO2 ratio <300 mm Hg OR SpO2 <90% on room air

> Chronic: Consider for patients on home O2 other than PRN.

> Type: Hypoxic: PaO2 <60mmHg OR SpO2 <90% on room air. Hypercapnic: PaCO2 >50mmHg, PaCO2 change of at least 10mmHg above baseline

Tip: Avoid post-operative respiratory failure for patients on mechanical ventilation as expected after surgery

DYING PROCESS A patient who is dying frequently has many underlying serious conditions that should be included in documentation EVEN IF the patient is in comfort care measures only: Acute respiratory failure/ Acute pulmonary edema, Acute renal failure/ Acute tubular necrosis, Acute liver failure, Delirium/Encephalopathy with cause and type,

Avoid: “multi-organ failure” specify each organ failure

COMFORT CARE

> Document: DNR/DNI status and POA status