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