Respiratory Failure [Documentation Suggestions]

  • Describe clinical signs and symptoms (e.g., abnormal blood gas levels, dyspnea, crackles, cyanosis, somnolence, etc.).
  • For patients with chronically abnormal ABG levels, note the baseline levels or if current levels vary from the patient’s norm.
  • Note underlying cause (e.g., AMI, pneumonia, CHF, massive stroke, etc.) and whether cause was chronic, chronic with acute exacerbation, or acute.

Additional notes:



Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: 7/7/03)