Shortness of breath

Improving physician documentation specificity

Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.

Asthma

Associated conditions (acute lower respiratory infection, COPD, bronchitis, status asthmaticus)
Severity and type - choose the severity based on the most severe impairment in the table below

Components of severity	Age (years)	Asthma	severity	classification
	Intermittent	Mild persistent	Moderate persistent	Severe persistent
Symptoms	All	<= 2 days/week	>2 days/week, but not daily	Daily
Nighttime awakenings	0-4	1-2 times/month	3-4 times/month	>1 time/week
Nighttime awakenings	>=5	3-4 times/month	>1 time/week but not nightly	Often 7 times/week
Short-acting beta-agonist use for symptom control	All	<= 2 days/week	>2 days/week, but not daily	Daily
Interference with normal activity	All	None	Minor limitation	Some limitation
FEV1 (predicted) or PEF (personal best)	<5	> 80%, normal FEV1 between exacerbations	> 80%	60-80%
FEV1/FVC	5-11	>85%	>80%	75-80%
FEV1/FVC	>=12	Normal	Normal	Reduced 5%

Form or type (cough variant, childhood, exercise-induced bronchospasm, extrinsic [allergic], idiosyncratic, intrinsic [nonallergic], late-onset, mixed, other [specify])
Status (uncomplicated, with acute exacerbation, with status asthmaticus)

Bronchitis

Acute (causal organism, when known) or chronic(simple or mucopurulent)

COPD

Is acute lower respiratory tract infection present? If so, document causal organism (e.g., Pseudomonas)
Does patient have respiratory failure (acute, chronic, acute on chronic)?
Is patient oxygen-dependent?

Emphysema

Type (unilateral, panlobular, centrilobular, other)
Is patient oxygen-dependent?

Influenza

Identified influenza virus (e.g., influenza A, novel influenza A, other types of influenza A)
Respiratory manifestation (pneumonia, lung abscess, laryngitis, pharyngitis, other manifestations [myocarditis, encephalopathy, otitis manifestation, gastrointestinal])

Pleural effusion

Is effusion malignant? If so, link to underlying neoplasm.

Pneumothorax

Type (spontaneous, chronic, post-procedural, traumatic)
If spontaneous, note if pneumothorax is primary, secondary or tension
Was pneumothorax present on admission?

Pneumonia

Type (aspiration, ventilator-associated, viral, bacterial)
Document causative organism when known or suspected (e.g., Klebsiella, gram-negative)

Pulmonary contusion

Link diagnostic evaluation to clinical diagnosis. CT findings are not equivalent to a diagnosis.

Pulmonary edema

Severity (acute, chronic). Only acute pulmonary edema can be coded for billing purposes.
Underlying cause (heart failure, chronic kidney disease, flash pulmonary edema)

Pulmonary embolism

Type (e.g., saddle, septic)
Is cor pulmonale present? If so, is it acute or chronic?
Is pulmonary embolus chronic (still present) or resolved? Do not use "history of PE" as it is ambiguous.
Is patient on anti-coagulant therapy? If so, is it for active treatment or prophylaxis?

Respiratory failure

Acute, chronic, acute on chronic
Type (list cause if known)

Type	Definition	Possible causes
Hypoxic	PaO2 < 60 mm Hg	Virtually all acute lung diseases that involve filling or collapse of alveolar units
Hypercapnic	PaCO2 > 50 mm Hg	Drug overdose, neuromuscular disease, chest wall abnormalities and severe airway disorders (asthma, COPD)
Hypoxic and hypercapnic	Both conditions exist	See above

Is the condition associated with COPD?
Is the condition post-procedural (e.g., acute post-procedural respiratory failure or acute on chronic post-procedural respiratory failure)

Tuberculosis

Acute versus chronic
Site (respiratory [lung, larynx, trachea, etc.], nervous system [meninges, brain, spinal cord, etc.])

Adult (main)|Emergency room (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

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