Congestive Heart Failure (CHF) [Documentation Suggestions]
Describe clinical signs and symptoms (e.g., exertional dyspnea, orthopnea, peripheral edema, pulmonary rales or crackles, or jugular vein distention, etc.).
Document work-up (e.g., chest x-ray, EKG, Swan-Ganz, echocardiogram, etc.).
Document treatment (e.g., diuretics, ACE inhibitors, digitalis, beta-blockers, O2, morphine sulfate, monitoring input and output, daily weights, etc.).
Etiology (e.g., valvular heart disease, renal failure with volume overload, congestive cardiomyopathy, myocardial ischemia, new onset atrial fibrillation, etc.).
Note LVEF, assessment for ACE inhibitor use, and contraindications for non-use of ACE inhibitors.
Note if CHF is valid by history. Chronic CHF may impact patient care, even in the absence of active treatment.
: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: