Did you know? The following commonly-used physician terminology of CAP/HAP all code to Simple Pneumonia:
- Community Acquired Pneumonia
- Healthcare Associated Pneumonia
- Nosocomial Pneumonia
To better demonstrate that your patient is as sick on paper as they are in the bed consider these documentation tips.
- Hospital documentation can include “Possible, Probable, or Suspected”
- Why are you are choosing Zosyn/Vancomycin instead of Rocephin/Azithromycin?
- Because you suspect GNR or MRSA – So tell us!
- “Pneumonia due to possible GNR, will Rx Zosyn”
- “Pneumonia due to possible MRSA, will Rx Vancomycin”
- Because you suspect GNR or MRSA – So tell us!
- Why are you adding Clindamycin or Flagyl?
- Because you suspect Aspiration – So tell us!
- “Pneumonia due to suspected Aspiration”
- Because you suspect Aspiration – So tell us!
Download the complete tip, Pneumonia.