COPD

COPD / Emphysema

Applicable for MSDRGs: 190, 191, 192

MD documentation should address:

1. Presenting symptoms: cough; SOB/dyspnea; respiratory effort and rate; lung sounds; weight fluxuations
2. CXR findings (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. EKG: new findings and subsequent changes
4. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure)
5. Sputum/C&S Findings: specify causative organism
6. Evidence of SIRS: Must have at least 2 of the following:
   • Tachycardia: Pulse>90
   • Tachypnea: RR >20
   • Temp >100.4 (38C) or <96.8 (36C)
   • WBC >12,000 or <4,000 or >10% bands
7. Relationship to asthma when present and include acute exacerbation or status asthmaticus if present
8. Acute exacerbation of COPD (decompensation) or acute bronchitis with COPD if present.
9. Relationship to bronchiectasis when present and include acute exacerbation if present
10. Pneumonia when present
11. Treatment with medications, procedures or therapies

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