I just started at a new hospice and don't agree with the way they want me to fill out the Hospice Item Set questions about Shortness of Breath.
For those who use Netsmart/McKesson, this focuses on the Respiratory assessment and HIS J2030A.
Situation: I admitted a GIP patient onto hospice services yesterday for metabolic encephalopathy. He has no history of O2 use, but was currently on O2 for comfort when I arrived. My preceptor told me to mark the box for "shortness of breath" and "shortness of breath while talking or eating or performing other ADLs" because it is ASSUMED that he would have SOB while performing those tasks. She also stated that if I were to click the "None" box, that would have a negative impact on our HIS scores.
In my opinion, an assessment is what I know and see, and I don't know that he is SOB. His respirations were WNL and were not labored.
Would you chart SOB or not?