Clinical Documentation Tip Sheets

Acute respiratory failure (eg, invasive or noninvasive ventilatory support needed or imminent) New Hypoxemia (See Respiratory) Pain (eg, inhibiting ability to cough or clear airway) not controllable in observation care (See General) Tachypnea that persists despite observation care Vertebral fracture that requires inpatient care (medical), as indicated by 1 or more of the following: –Instability or impending instability of vertebral body or column –New neurologic deficit –Concomitant cranial fractures –Malalignment (eg, posttraumatic misalignment, severe kyphosis with sagittal plane deformity)

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