Pulmonary Edema

Diagnosis: Pulmonary Edema

Applicable for MSDRGs: 189

MD documentation should address:

1. Presenting symptoms: dyspnea and/or cough; CP + location and intensity; hemoptysis; respiratory rate; heart rate; abnormal heart or pulm sounds; skin color; hx of aspiration, trauma, smoke inhalation or surgery; chronic cardiac or lung disorders; recent blood transfusions
2. CXR findings: pleural effusions; emphysema; atelectasis /infiltates; elevated hemidiaphragms; CHF (systolic, diastolic or combined, left, right)
3. EKG: new findings and subsequent changes
4. O2 Sat or ABG Findings: hypoxia; acute/chronic/acute-on-chronic respiratory failure; ARDS; hypo- or hypercapnia; acidosis or alkalosis
5. 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
6. Evidence of encephalopathy and cause if known (metabolic, specific organ dysfunction)
7. Hx of acute MI: State relationship and when the MI occurred. If patient had MI, what episode of care is this?
8. Renal failure (acute, chronic or acute on chronic, ATN) and any relationship between RF and pulm edema
9. Any infectious disease process
10. Treatment with medications, procedures or therapies

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