Our hospital is going to be monitored soon by joint commission. From what i understand they are looking at at our care plans. We are pretty good at our psych diagnosis but we reportedly need to brush up on our adding medical diagnosis for our patients with conditions. The main one i see is patients with a history of asthma, but most of them only have excercise induced asthma and only have a prn albuterol inhaler and usually don't even use the inhaler while they are in the hospital.
I need help with what type of dg. Would this be. I've been thinking high risk for ineffective airway secondary to asthma but what would i use for aeb since it is just hx.
Or something else. Most of them don't have symptoms.
The other issues is someone by have a sore throat ever once in a blue moon. Do i just add pain to the care plan and/or use knowledge deficit?
It's been a while since i did these medical plans.