A patient has a diagnosis of pneumonia.Which entry should the nurse chart to help with financial reimbursement?
A) Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.
B) Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints.
C) Breathing without difficulty. Sitting up in bed watching TV. Had a good day.
D) Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

Question

Quizplus · Accepted Answer

Accurate documentation of supplies and equipment used assists in accurate and timely reimbursement.Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency.None of the other options had equipment or supplies listed.Avoid using generalized,empty phrases such as "status unchanged" or "had a good day." Do not enter personal opinions-stating that the patient is cooperative is a personal opinion and should be avoided."Finally,patient had no complaints" is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care.

A Patient Has a Diagnosis of Pneumonia