Asthma, Bronchitis, and COPD [Documentation Suggestions]

  • Note any history of cigarette smoking, recent cold, or upper respiratory tract infection.
  • Describe clinical signs and symptoms (e.g., wheezing, sore throat, cough, bronchospasm, recurrent chest tightness, etc.).
  • Document work-up (e.g., chest x-ray, peak flow monitoring, pulmonary function tests, ABGs, etc.).
  • Document treatment (e.g., oxygen, bronchodilators, epinephrine, corticosteroids, antibiotics, pulmonary rehabilitation, etc.).
  • Note any status asthmaticus.
  • Note COPD if valid by history. COPD may impact patient care, even in the absence of active treatment.
  • Specify type of bronchitis (acute, chronic, asthmatic, etc.).

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)