• Document early or late onset
• If with dementia, document as
  • With behavioral disturbance (e.g., combative and/or aggressive behavior), OR
  • Without behavioral disturbance

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• Initial versus recurrent episode
• Mild, moderate or severe
• With or without psychotic features
• If in remission, document if depression is in partial or full remission

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• Document if present on admission.
• If urinary tract infection (UTI) is related to a device, clearly indicate this fact by using terms like "due to" or "secondary to."
• Identify specific site (e.g., bladder, kidney, urethra).
• When known or suspected, document causative organism (e.g., E coli, candida).

. . .

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• Document if present on admission
• Document site and laterality
  • Lower leg
  • Foot
  • Heel
• Document stage, if known

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• Document the type of pneumonia being treated.
  • Aspiration
  • Ventilator-associated
  • Viral
  • Bacterial

• Even in cases of health care-associated pneumonia (HCAP) , if sputum culture reveals an organism, link organism to the pneumonia. Examples include:

  • Methicillin-sensitive S aureus
  • Klebsiella
  . . .

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• Document hematuria if present.
• Document type:
  • Acute versus chronic
  • Interstitial
  • Trigonitis
• When known or suspected, document causative organism (e.g., E. coli, candida)

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