Summary documents diagnosis of pneumonia

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Reference no: EM133645314

A 72-year-old female patient's clinical picture shows pneumonia, PEG tube, current CVA, worsening cough, and increased breath sounds. The physician's discharge summary documents a diagnosis of pneumonia; however, review of the medical record demonstrates extensive clinical indicators which include a progress note dates 5/18 that states the patient probably aspirated. Chest x-ray on 5/19 shows positive infiltrate. The coder also identifies a positive swallowing study that was done on 5/18. A progress note dated after the swallowing study indicates the patient was put on aspiration precautions. A physician order on 5/18 indicates to elevate the head of the bed.

Reference no: EM133645314

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