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UNM Documentation Tips (redirected from UNM Documentation Guidelines)

Page history last edited by kzchang@salud.unm.edu 3 months ago

This is a repository of the UNM HIM CDI & Coding Guidelines to help with Documentation:


You can find the most recent updated tipsheets at the intranet page: https://hospitals.health.unm.edu/intranet/HIM/cdi.shtml 


These are also within the Moodle practice management modules in the Inpatient Diagnosis and Specificity > Documentation Tips module resources.


General Best Practice words summary card: Best Practice Documentation Examples.docx  


Here are the available common ones: 



Malnutrition 1 Rev 10.05.17.pdf

Substance Use Page 1_2 TipSheet Update Jan 2020.docx

Alcohol Disorder Tip Card-combined.docx

Congestive Heart Failure_.pdf

Tip Sheet Hospital Medicine.docx



UNMH Guideline Pediatric Encephalopathy_Final.doc

UNMH Guideline Pediatric Shock_FINAL.doc

UNMH Guideline Pediatric SIRS Sepsis_Final.doc

Malnutrition, Pediatric CDI and Coding Guideline.pdf

Respiratory Failure (Pediatric) Guideline_final.doc

Tip Sheet Pediatrics.docx


L&D Top Ten Queries:

Top Ten workstation tip sheet



Acute Respiratory Failure

 Diagnostic criteria: Hypoxemic, Hypercapnic, or both - with signs of respiratory difficulty on exam

  • Acute hypoxemic
    • pO2 <60mmHg on RA per ABG, or
    • SpO2 <91% on RA per pulse oximetry, or
    • P/F ratio <300 on O2 - with new O2 need (not chronic supplemental oxygen-dependent)
  • Acute on chronic hypoxemic
    • worse dyspnea w/increased O2 need, or
    • worse hypoxemia: decrease in baseline pO2 by >10mmHg or SpO2 <91% on usual home O2
      • Example: home O2 at 2 L/min and baseline SpO2 >91%, but pt with dyspnea and requiring 4 L/min to keep SpO2 >91%
  • Acute hypercapnic (acute retention, impaired ventilation)
    • pCo2 > 50mmHg with pH <7.35
  • Acute on chronic hypercapnic
    • pCO2 > 50mmHg with pH <7.35, or
    • increase in baseline pCO2 by ≥10mmHg on ABG


 Tip: COPD patients without home O2 need because baseline SpO2 >91% are not in chronic respiratory failure.


Examples of word specifiers:

  • "acute hypercapnic respiratory failure with respiratory acidosis" (not just "pt has respiratory acidosis")
  • "acute hypoxemic respiratory failure as evidenced by P/F ratio <300 on 3L/min supplemental oxygen" or pO2 <60mmHg on room air...
  • "acute exacerbation of chronic hypoxemic respiratory failure requiring a increase in supplemental oxygen above baseline..."


"Respiratory insufficiency" describes a symptom and some sort of hypoxia, but probably in the pO2 60-79.9mmHg or SpO2 91-95% range.

  • If patient meets diagnostic criteria for respiratory failure, you may be queried to specify.



Acute Respiratory Failure in Pediatrics (29 days -18 yrs); (neonates ≤28 days/old)

Diagnostic criteria: similar numbers to adults, but at UNMH consensus guideline is that neonate respiratory failure is defined by SaO2 87% or requiring more than 3 LPM NC or requires High Flow Oxygen.

  •  Hypoxemic respiratory failure
    • pO2 < 60 mmHg on room air, or
    • P/F ratio <300 on supplemental oxygen, or
    • 10-15 mmHg decrease in pO2 from baseline (if known)
  • Hypercapnic respiratory failure
    • pCO2 > 50 mmHg with pH <7.35, or
    • VBG in lieu of ABG
    • End-tidal CO2 level >45 mmHg on capnography
    • 10-15 mmHg increase in baseline pCO2 (if known)

Word specifics:

  • In babies 28 days old, "respiratory insufficiency" = respiratory failure.
  • In pediatric hospitalized patients, if SpO2 >87% on RA or not requiring more than 3 LPM NC, you can use "acute respiratory distress" to indicate higher severity of illness.
    • Different than adults where we try not to use "acute respiratory distress" or "acute respiratory insufficiency."


 Tip: Check in these babies whether they require High Flow Oxygen before using either term (respiratory insufficiency or failure).

 Documentation guideline from Pediatrics team attached.



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