DX Pneumonia Documentation Example

During a recent audit, nursing documentation was noted to be non-compliant in meeting the requirements set forth by Medicare for supporting medical necessity of skilled services. Below is an example of the documentation requirements for a single diagnosis represented as the admitting diagnosis for skilled care. Following this list is an example of fictional (for educational purposes only) documentation that would meet the Medicare requirements and therefore protect the claim made by the facility. Note that the example of compliant documentation is no more lengthy than a typical chart entry.

DOCUMENTATION
Dx. PNEUMONIA

1. Complete vital signs
   • temperature increases or decreases
   • fever
   • chills
2. Auscultation of lungs (presence of rales, congestion)
3. Cough (painful, hacking, productive, non-productive)
4. Sputum (describe amount and color)
5. Ability to cough and deep breath
6. Color (flushed face, cyanosis or pallor)
7. Dyspnea
8. Nutritional status / hydration status
9. Intake and output
10. Immobility and weakness (Is resident ambulatory or bed ridden? Is he able to change position in bed by self?
11. Frequent changes in position
12. Oxygen therapy (liter flow, type used, how often)
13. Suctioning
14. Medication (antibiotic therapy)
15. Restlessness, headaches and skin condition
16. Endurance level with activity
17. Disorientation

The goals of therapy at this time are to increase ambulation to 50 feet (prior level of function/PLOF) from 10 feet (previous level of function last week), to progress to CGA transfers (PLOF) from Mod Assist X 1 (previous level of function last week).

2-10-11 @ 1430—“Resident noted to be resting in bed with HOB elevated to 45 degrees per resident request due to dyspnea reported before lunch today. Temp-99.8, Pulse-88, B/P-140/78, Resp-22. Note Tylenol 650mg given at 1100 today for temp 101.1. Rsd denies feeling feverish or “chills.:” Lung CTA but diminished in all lobes. No cough noted or reported, however small amount greenish-yellow sputum noted on tissues at beside. Rsd able to cough and deep breath upon command, produces no sputum at this time. Skin pink, warm, dry with no facial flushing noted. Reports dyspnea upon lying flat, denies dyspnea when sitting upright. Oxygen at 2 liters per nasal cannula continuous, O2 sat 90% at this time. Poor po intake at lunch today, (less than 25%), refuses supplement at this time but drinks 120 cc water. Requires mod assist X 1 transfer sit to stand and to ambulate with walker 20 feet to the bathroom, resp rate from 22 at rest to 36 after ambulation for toileting, voided X 1 this shift of clear yellow urine. No BM reported yet this shift. Resident independent with bed mobility, however requires assistance with pillow positioning. Verbal cues given to change position frequently. No suctioning required at this time. Levaquin 500mg IV q day continues, infusing as ordered at this time via saline lock, patent with no s/s complication. Awake, alert, and oriented to self, place, and time. Denies pain at this time, denies needs at this time.”