Pneumonia [Documentation Suggestions]
Describe clinical signs and symptoms (e.g., fever, chills, cough, dyspnea, tachypnea, crackles or rales, etc.).
Note radiological and laboratory findings - include rationale for disagreement with any findings (e.g., negative chest xray, culture, etc.).
Describe preadmission treatment that may have affected radiological or laboratory results (e.g., prior antibiotic use, etc.).
Document causative agents based on clinical findings, culture results, and/or response to treatment (e.g., gramnegative cocci, Klebsiella because of reddish “current jelly” sputum, etc.).
If aspiration pneumonia, note cause of aspiration (e.g., dysphagia, etc.).
Note patient’s current pneumococcal and influenza vaccination status.
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