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Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia #1
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@secondmedicalop
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When possible, specify the organism causing it. If the organism is not known, use the words possible, suspected or probable.
Example: If using vancomycin for the treatment of pneumonia, MRSA pneumonia is being suspected, so the assessment could read: “Possible MRSA pneumonia, using IV vancomycin for its treatment.”
Marco A. Ramos MD, CCDS