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Documentation Tip of the Week: Acute Respiratory Failure

Posted on Wed, Sep 16, 2015
Documentation Tip of the Week: Acute Respiratory Failure

Our weekly feature of documentation tips for clinicians.

Acute Respiratory Failure

  • DEFINITION: Present if any 2 of these 3 criteria met:
    • pO2< 60mmHg (conservatively the equivalent to pulse ox 88% on Room Air)
    • pCO2> 50mmHg with pH < 7.35 (means acute!)
    • Respiratory Distress (document through the physical exam)
 
  • ICU admission &/or intubation w/ mechanical ventilation not required to meet this definition
  • Do NOT need an ABG
  • Respiratory distress – please document in the chart!
    • Tachypnea (RR>20)
    • Brief, fragmented speech
    • Retractions or use of accessory muscles
    • Inability to lie supine
    • Diaphoresis
    • Cyanosis &/or dusky skin
    • Depressed or altered mental status
    • “Paradoxical” Respirations



Timothy Brundage, MD, is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips or ask him about specific documentation issues by emailing him at DrBrundage@gmail.com.

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