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”
  • Why are you adding Clindamycin or Flagyl?
    • Because you suspect Aspiration – So tell us!
      • “Pneumonia due to suspected Aspiration”

Download the complete tip, Pneumonia.