Clarification Regarding Shortness of Breath Documentation

Clarification Regarding Shortness of Breath Documentation

Effective January 1, 2017, CMR Reviewers will be requiring documented evidence of shortness of breath or trouble breathing when the resident attempts to lie flat, or avoids lying flat because of shortness of breath, that goes beyond a “check mark” or initials in a box. Shortness of breath is a serious condition and may be an indication of a change in condition that requires further assessment and care planned interventions. A check mark or initials in a box is not considered an assessment.

An assessment should include, but is not limited to:

  • Interviews with the resident, family members or significant other (if appropriate) and facility staff from all shifts.
  • Observations of the resident during various activities, sitting at rest, and when in bed.
  • The onset, was it sudden or gradual, are there certain activities that make the shortness of breath worse? or better?
  • A review of the resident’s medical history including any diagnoses or conditions that may affect respiratory status.
  • Does the resident use any medications that may affect respiratory function?
  • Is the shortness of breath accompanied by a fever, cough, abnormal lung sounds, or chest pain?

The resident's care plan should identify diagnoses and activities that may exacerbate symptoms of shortness of breath, the measurable goal of treatment, and the interventions utilized to decrease symptoms of shortness of breath.