Definition:
The person has reported or been observed to be breathless or “short of breath.”
Process:
Ask the person if he/she has experienced shortness of breath. If the answer is affirmative, determine if the symptom occurred with strenuous activity, during normal day-to-day activity, or when resting. If the person is unable to respond, review the clinical record and consult with other clinicians and the person’s family.
Coding:
Select the appropriate code from the list below. Code for the most severe occurrence during the last 3 days. If the symptom was absent over the last 3 days, but would have been present had the person undertaken activity, code according to the activity level (day-to-day or moderate) that would normally have caused the person to experience shortness of breath.
Absence of symptom
Absent at rest, but present when performed moderate activities
Absent at rest, but present when performed normal day-to-day activities
Present at rest
Moderate activities include some type of physical exercise, such as walking a long distance, climbing 2 flights of stairs, or gardening.
Normal day-to-day activities include all ADLs (bathing, transferring, etc.) and IADLs (e.g., meal preparation, shopping, etc.).