Pneumonia [Documentation Suggestions]

  • Describe clinical signs and symptoms (e.g., fever, chills, cough, dyspnea, tachypnea, crackles or rales, etc.).
  • Note radiological and laboratory findings - include rationale for disagreement with any findings (e.g., negative chest xray, culture, etc.).
  • Describe preadmission treatment that may have affected radiological or laboratory results (e.g., prior antibiotic use, etc.).
  • Document causative agents based on clinical findings, culture results, and/or response to treatment (e.g., gramnegative cocci, Klebsiella because of reddish “current jelly” sputum, etc.).
  • If aspiration pneumonia, note cause of aspiration (e.g., dysphagia, etc.).
  • Note patient’s current pneumococcal and influenza vaccination status.

Additional notes:



Source: "Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from web site: 7/7/03)