Heart Failure

Diagnosis: Heart Failure

Applicable for MSDRGs: 291, 292, 293

MD documentation should address:

1. Presenting symptoms: respiratory effort; lung sounds; weight fluxuation; peripheral edema; or other contributing conditions
2. CXR findings (i.e. pleural effusion; cardiomegaly; etc)
3. Cardiac study findings: (i.e. diastolic/systolic dysfunction; ejection fraction; valve disorders)
4. EKG: new findings and subsequent changes
5. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure)
6. Hx of acute MI? State relationship and when the MI occurred. If patient had MI, what episode of care is this?
7. Heart failure status as acute; chronic; or acute on chronic
8. Location or type of heart failure: systolic; diastolic; combined; right or left heart failure
9. Relationship with other disease processes as appropriate; state cause and effect between diagnoses. (i.e. Hypertension & CHF or Hypertensive Heart Disease). If HTN, state if benign; accelerated or malignant.
10. Relationship between any existing renal failure (acute, chronic, acute-on-chronic) and heart failure.
11. Was the patient decompensated and if so what was it due to? (i.e. RF, volume overload, pulmonary edema; cardiac condition)
12. Treatment with medications, procedures or therapies

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