Clinical Documentation Improvement Series #1, Documenting Acute Respiratory Failure
Respiratory failure is one of the most common diagnoses in the intensive care unit. When this problem is acute (or acute on chronic), it has to be noted properly in the documentation. Criteria used to diagnose it are a PaO2 lower than 60mmHg, a PaCO2 greater than 50 mmHg, SaO2 lower than 91% and PaO2/FIO2 ratio(PAFI) < 300. The clinical judgement of the physician has to be applied on top of the use of the variables. When documenting acute on chronic respiratory failure it is important to document the baseline variable and the change from baseline. A decline in 10 mmHg in the PaO2 , an increase of 10 mmHg of the PaCO2 and the increased demand for oxygen is a patient chronically using the oxygen supplementation can support the diagnosis. In addition, if the respiratory failure includes hypercapnia (or respiratory acidosis) it has to be documented too. Finally, the use of a ventilator has to be reported together with the duration of it or if the mechanical ventilation is related to a serial procedure.
Marco A. Ramos MD, CCDS