Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia #1

in health •  11 months ago  (edited)

Picture Steemit CDI Tips 1.jpg

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

In order to quote from this post (using Chicago style) please use the following:
Marco A. Ramos, “Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia”, SMO Blog (blog), August 12, 2019, https://steemit.com/health/@secondmedicalop/clinical-documentation-improvement-series-14-tips-for-documenting-the-organism-causing-pneumonia-1

Links to the Previous Posts in this Series

- Clinical Documentation Improvement Series #1. Documenting Acute Respiratory Failure
- Clinical Documentation Improvement Series #2. How and When Do We Use the Body Mass Index (BMI)
- Clinical Documentation Improvement Series #3. Is it Delirium or Encephalopathy?
- Clinical Documentation Improvement Series #4. Documenting Myelopathies and Radiculopathies
- Clinical Documentation Improvement Series #5. Documenting Electrolyte Imbalances.
- Clinical Documentation Improvement Series #6. Documenting Electrolyte Imbalances.
- Clinical Documentation Improvement Series #7. Documenting Electrolyte Imbalances.
- Clinical Documentation Improvement Series #8. The Importance of “Present on Admission”
- Clinical Documentation Improvement Series #9. If the Patient has Elevated Troponins...
- Clinical Documentation Improvement Series #10. Documenting Pneumonia
- Clinical Documentation Improvement Series #11. If the Patient Has Not Eaten for Several Days Before Admission…
- Clinical Documentation Improvement Series #12. Documentation of Acute Renal Failure
- Clinical Documentation Improvement Series #13. Documenting Liver Failure

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