Clinical Documentation Improvement Series #10. Documenting Pneumonia
Pneumonia is one of the most common infections that require inpatient care. The documentation of pneumonia needs to be very specific, in order to capture a good reflection of what really happened during the hospitalization. Many different infectious agents can cause pneumonia. The one that is being treated, even if presumptive needs to be documented. The terms “possible”, “probable”, “not ruled” out and “likely“ can always be used. The association with sepsis, respiratory failure and mechanical ventilation, if present, cannot be omitted because they will show the severity of illness and the risk of mortality of the case.
Marco A. Ramos MD, CCDS