Clinical Documentation Tip Sheets

Respiratory

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

RESPIRATORY FAILURE

> Acute: Document each of the following: Respiratory distress: (eg, tachypnea, use of accessory respiratory muscles) 1.

O2 requirement : ≥4L O2 required to maintain saturation of 92% for ≥2 hours OR ≥2L of O2 required for >24 hours 2. Hypoxia or hypoxemia: PaO2 <60 mm Hg on room air OR PaO2 /FiO2 ratio <300 mm Hg OR SpO2 <90% on room air 3.

> 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

PNEUMOTHORAX

LUNG CANCER

PNEUMONIA

> Type: Spontaneous, Tension, Traumatic, Iatrogenic (post operative) Tip: post-operative and iatrogenic pneumothorax code to the same code (complication), avoid the term post-operative if you only mean timeframe

Document: primary site and metastatic sites.

> Type/Organism: Aspiration, gram positive, gram negative, MRSA, MSSA, Klebsiella, pseudomonas, etc. Tip: Adding the type/organism to pneumonia may change it from simple to complex pneumonia. Tip: HAP, CAP, HCAP is not recognized as pneumonia types and code to unspecified pneumonia.

Tip: Avoid history of cancer if the cancer is still being treated even after surgical removal of the cancer.

PULMONARY EDEMA

COR PULMONALE

COPD > Acuity: Chronic, acute on chronic (exacerbation)

> Acuity: Acute or Chronic

> Acuity: Acute or chronic

> Type: cardiogenic, or non cardiogenic

> Link to pulmonary embolism when appropriate

> Document: associated acute or chronic respiratory failure > Document: other associated lung conditions; asthma, bronchitis, bronchiectasis, emphysema

Tip: Remember to add acuity. Without acuity pulmonary edema defaults to chronic.

> Document: tobacco use, dependence or history