Pulmonary Embolism

Diagnosis: Pulmonary Embolism

Applicable for MSDRGs: 175, 176

MD documentation should address:

1. Presenting symptoms: time of onset and duration of: dyspnea and/or cough; CP + location and intensity; hemoptysis; respiratory rate; heart rate; abnormal heart sounds; calf or leg pain; recent ortho surgery; hx of DVT or PE; obesity; use of high-estrogen hormonal contraceptive agents; chronic cardiac or lung disorders; clotting disorders
2. CXR findings: pleural effusions; emphysema; atelectasis /infiltates; elevated hemidiaphragms; CHF (systolic, diastolic or combined, left, right)
3. Radiologic Findings: evidence of PE and/DVT
4. EKG: new findings and subsequent changes
5. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure, hyper- or hypocarbnia)
6. Lab Values: D-Dimer; and/or other tests with evidence of PE
7. Hx of acute MI: State relationship and when the MI occurred. If patient had MI, what episode of care is this?
8. **If patient has poor cardiopulmonary reserve, negative L/E exam, a nondiagnostic lung scan and is still being treated for a suspected or probable PE, it should be documented as a suspected or probable PE.**
9. Treatment with medications or procedures

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