Documentation Tip of the Week: Pneumonia

Posted on Wed, Mar 11, 2015
Documentation Tip of the Week: Pneumonia

Did You Know? Did You Know? Community Acquired Pneumonia, Healthcare Associated Pneumonia and Nosocomial Pneumonia all code to Simple Pneumonia?

To demonstrate that your patient is as sick on paper as they are in the bed consider these documentation tips: 

  • Hospital documentation can include “Possible, Probable, or Suspected”  
  • Why are you are choosing Zosyn/Vancomycin instead of Rocephin/Azithromycin? o Because you suspect GNR or MRSA? So tell us!
    • “Pneumonia due to possible GNR, will Rx Zosyn”
    • “Pneumonia due to possible MRSA, will Rx Vancomycin”
  • Why are you adding Clindamycin or Flagyl? Because you suspect Aspiration?  So tell us!
    •  “Pneumonia due to suspected Aspiration”

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

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