Respiratory System Dx with Vent Support

Diagnosis: Respiratory System Dx with Vent Support

Applicable for MSDRGs: 207, 208

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; any others that would support a respiratory principal diagnosis.
2. CXR findings: pleural effusions; emphysema; atelectasis /infiltates; elevated hemidiaphragms; CHF (systolic, diastolic or combined, left, right); other findings that would support a respiratory principal diagnosis
3. CT/MRI Findings: evidence of pneumothorax; PE; malignant or benign respiratory neoplasms; major chest trauma; interstitial lung dz; other findings that would support a respiratory principal diagnosis
4. O2 Sat or ABG Findings: hypoxia; acute/chronic/acute-on-chronic respiratory failure; ARDS; hypo- or hypercapnia; acidosis or alkalosis; other findings that would support a respiratory principal diagnosis
5. Lab values: evidence of infectious disease process.
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. **Documented time of continuous invasive mechanical ventilation**
8. Treatment with medications, procedures or therapies

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