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.

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)