Cardiac Arrest, Pneumonia and Respiratory Failure

Cardiac Arrest

Cardiac Arrest

 

• When there is a “Cardiac Arrest” the documentation should include:
    --due to underlying cardiac condition
    --due to other underlying condition
    --cardiac arrest, cause unspecified
• In addition, specify if:
    --postprocedural cardiac arrest following cardiac surgery
    --postprocedural cardiac arrest following other surgery
    --intraoperative cardiac arrest during cardiac surgery
    --intraoperative cardiac arrest during other surgery
• Always document the “underlying cardiac condition” if known
• Document any associated diagnoses/conditions

Pneumonia

• Document causative organism (if known)
• Document mechanism:
    --Aspiration
    --Ventilator-associated
    --Radiation-induced
    --Other (specify)
• Document any associated illness:
    --Respiratory failure
    --Sepsis
    --Underlying lung disease
    --Other (specify)
• Document history of tobacco use—present or past

Respiratory Failure

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• Document acuity:
    --Acute
    --Chronic
    --Acute on chronic
• Document inclusion of:
    --Hypoxia
    --Hypercapnia
• Document tobacco:
    --Use
    --Abuse
    --History of
• Document any associated diagnoses/conditions