Clinical documentation is required to be compliant with Medicare and other regulatory standards for accurate coding and to reflect the overall severity/acuity of illness and risk of mortality. Below are some important key elements to keep in mind when documenting the diagnosis of pneumonia.
A physician must determine the diagnosis of pneumonia and document the specific cause if known. If the specific clinical information is not documented in the medical record, HIM Coding Staff and/or Clinical Documentation Improvement Specialist must seek clarification or “query” the physician. When completing the required documentation for pneumonia, it is important to note the clinical findings substantiating pneumonia, including the results of the chest x-ray, sputum culture, white blood cell count and temperature of the patient.
When treating a patient with a diagnosis of aspiration pneumonia, it is necessary for the clinical documentation to substantiate a diagnosis of pneumonia and not just “aspiration.” It is also necessary for the physician to link the term “aspiration pneumonia” to any causative organisms, such as “Staphylococcus pneumonia" and/or a precursor (causal) event (i.e. choking, coughing, dysphagia, vomiting), which may have contributed to the aspiration pneumonia. For example, “Aspiration pneumonia due to Staphylococcus.”
Source: The Clinical Documentation Improvement Specialist’s Handbook, by Colleen Garry, RN, BS, and published by HCPro, Inc.
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