Clinical Documentation Tip Sheets

IMAGING REPORTS AND PATHOLOGY REPORTS

> Remember t o add to your notes the imaging reports and pathology reports and indicate the clinical significance of the findings.

COPD

Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (see General) New need for intubation and mechanical ventilation Clinical signs of respiratory fatigue (eg, use of respiratory accessory muscles, paradoxical motion of the diaphragm, intercostal retractions) Altered mental status that is severe or persistent Increase in pre-existing supplemental oxygen requirement to maintain oxygenation at baseline level despite observation care. Hypoxemia (1 of the following): -Severe hypoxemia (PaO2 less than 55 mm Hg (7.3 kPa) despite inspired oxygen (FiO2) greater than 40%) -New-onset room-air hypoxemia (SpO2 less than 90%, PaO2 less than 60 mm Hg) that persists despite observation care Hypercarbia (1 of the following): -Severe hypercarbia with PaCO2 greater than 60 mm Hg or respiratory acidosis with pH 7.25 or lower -Moderate hypercarbia (PaCO2 between 45 mm Hg and 60 mm Hg) with moderate respiratory acidosis (pH between 7.26 and 7.35) that persists despite observation care

ACUTE VIRAL ILLNESS

Inpatient admission is indicated for 1 or more of the following: Hypoxemia (See COPD) Ventilatory assistance needed (eg, mechanical ventilation, new need for noninvasive ventilation) Severe tachypnea (eg, respiratory rate greater than 30 breaths per minute) Tachypnea that persists despite observation care Accessory muscle use Respiratory retractions (eg, suprasternal, intercostal, or subcostal) Airway obstruction (eg, viral epiglottitis, airway narrowing from infectious mononucleosis)

ASTHMA Inpatient admission is indicated for 1 or more of the following: Hemodynamic instability (see General) Altered mental status is severe or persistent

Ventilatory assistance needed (eg, mechanical ventilation, noninvasive ventilation) Peak expiratory flow rate less than 25% of predicted or personal best before treatment Peak expiratory flow rate less than 40% of predicted or personal best after treatment Hypoxemia (see COPD) PaCO2 elevation from baseline (or from normal if no previous measurement) of 2 mm Hg (0.27 kPa) or greater Respiratory finding (eg, dyspnea, accessory muscle use) that persists despite observation care (eg, beta agonist response not sustained for at least 3 hours) Peak expiratory flow rate between 40% and 60% of predicted or personal best despite observation care Radiographic evidence of complication requiring inpatient treatment (eg, tension pneumothorax)