The patient is a 13 y/o female who presents to the physician’s office with a fever, cough, and chest crackling.

Indicate if the medical documentation is complete. If the documentation is considered not complete, indicate what the provider needs to complete for an accurate code to be selected.

The patient is a 13 y/o female who presents to the physician’s office with a fever, cough, and chest crackling. The patient becomes hypoxic while in the office and is then admitted to the inpatient facility with acute respiratory failure. The patient is maintained on ventilation for three days, still hypoxic, with lab work demonstrating bacterial growth of klebsiella pneumoniae. At day five, the patient is much improved and determined stable for discharge with a final diagnosis of bacterial pneumonia.

Is this medical documentation complete? 

If no, what documentation does the provider need to complete for an accurate code to be selected?

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