Clinical Documentation Improvement Series #14. Tips for Documenting the Organism Causing Pneumonia #1
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.”
