When possible, specify the organism causing it.
If the organism is not known, use the words possible, suspected or probable.
Example: If using vancomycin for the treatment of pneumonia, MRSA pneumonia is being suspected, so the assessment could read: “Possible MRSA pneumonia, using IV vancomycin for its treatment.”
Marco A. Ramos MD, CCDS
In order to quote from this post (using Chicago style) please use the following:
Marco A. Ramos, “Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia”, SMO Blog (blog), August 12, 2019, https://goldvoice.club/steem/@secondmedicalop/clinical-documentation-improvement-series-14-tips-for-documenting-the-organism-causing-pneumonia-1
Links to the Previous Posts in this Series
- Clinical Documentation Improvement Series #11. If the Patient Has Not Eaten for Several Days Before Admission…