How to Write an A&P for CHF Exacerbation (With Examples)

Congestive heart failure exacerbation ranks among the most frequent admissions for hospitalists. Despite seeing these patients daily, many physicians default to vague documentation that undersells care complexity and leaves money on the table.

This guide shows you how to write an assessment and plan that accurately captures patient acuity, supports appropriate reimbursement, and demonstrates evidence-based care.

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Why CHF Documentation Matters

Poor documentation affects quality metrics, leads to claim denials, and creates medicolegal risk. Compare these scenarios:

• “CHF exacerbation” - Vague, does not capture severity
• “Acute on chronic systolic heart failure with reduced ejection fraction, NYHA Class III” - Specific, supports higher acuity coding

The second example is more accurate, not more complex. Accurate documentation benefits coders, payers, quality teams, and the next physician reading your note.

Building Your Problem List for Better Reimbursement

Problem title specificity directly affects ICD-10 code assignment. Consider how you name CHF problems:

Specify Heart Failure Type

Vague	Specific	Why It Matters
CHF	Systolic heart failure	Distinguishes HFrEF from HFpEF
Heart failure	Heart failure with reduced ejection fraction (HFrEF), EF [EF]%	Captures preserved vs reduced
CHF exacerbation	Acute on chronic systolic heart failure	Indicates acute decompensation

Document NYHA Classification

NYHA class matters for care planning and captures functional limitation:

• Class I: No limitation of physical activity
• Class II: Slight limitation; comfortable at rest
• Class III: Marked limitation; less than ordinary activity causes symptoms
• Class IV: Unable to carry on any activity without symptoms

Include Etiology When Known

• Ischemic cardiomyopathy
• Non-ischemic dilated cardiomyopathy
• Hypertensive heart disease
• Valvular heart disease
• Alcoholic cardiomyopathy

Key Components of a CHF A&P

1. Assessment Summary

Start with a one-liner capturing the clinical picture:

“[AGE] year-old [SEX] with [PMH] presenting with acute decompensated heart failure, likely triggered by [dietary indiscretion / medication non-adherence / arrhythmia / infection]. Current NYHA Class [III/IV]. Last known EF [EF]% on [date].”

This immediately orients the reader to:

• Patient context
• Acuity (acute decompensation)
• Likely precipitant
• Functional status
• Baseline cardiac function

2. Volume Status Documentation

Volume status drives CHF management. Document it explicitly:

Physical Exam Findings to Include:

• JVP in cm (not only “elevated”)
• Peripheral edema grade and distribution
• Lung exam findings
• Daily weights with trend
• I/O balance

Example:

“Volume overloaded with JVP 12 cm, 2+ bilateral lower extremity edema to mid-calf, bibasilar crackles. Weight 98.2 kg, up 4.5 kg from dry weight of 93.7 kg.”

3. Etiology Workup

Document your reasoning about what caused this decompensation:

Common Precipitants (the “FAILURES” mnemonic):

• Forgot medications
• Arrhythmia / Anemia
• Ischemia / Infection
• Lifestyle (dietary indiscretion, alcohol)
• Upstream issues (thyroid, pregnancy)
• Renal failure
• Embolism (PE)
• Stenosis (valvular disease)

Document the workup:

“Etiology: Likely dietary indiscretion (patient reports high-sodium meal at restaurant) superimposed on baseline medication non-adherence. No EKG changes to suggest ACS. TSH normal. No fever or leukocytosis to suggest infection.”

4. GDMT Documentation

Guideline-directed medical therapy documentation matters. For each medication class, document:

• Whether patient is on it
• If not, why not (contraindication, intolerance, not yet initiated)
• Target dose vs current dose

Core HFrEF Medications:

Class	Examples	Target Doses
ACEi/ARB/ARNi	Sacubitril-valsartan	97/103 mg BID
Beta-blocker	Carvedilol, metoprolol succinate	Carvedilol 25mg BID
MRA	Spironolactone, eplerenone	Spironolactone 25-50mg
SGLT2i	Dapagliflozin, empagliflozin	Dapa 10mg, Empa 10mg

Example GDMT Documentation:

“GDMT status: On carvedilol 12.5 mg BID (uptitrate as tolerated once euvolemic), sacubitril-valsartan 49/51 mg BID (mid-titration dose; target is 97/103 mg BID as tolerated per PARADIGM-HF), spironolactone 25 mg (at target). Will initiate SGLT2 inhibitor per guideline indication (verify eGFR threshold per current FDA labeling for specific drug and indication before starting). Per DAPA-HF, mortality benefit is independent of diabetes status.”

Evidence to Cite

Reference landmark trials when they inform your management. This demonstrates evidence-based practice and supports your clinical reasoning:

Key Trials for HFrEF

PARADIGM-HF (2014)

• Sacubitril-valsartan reduced cardiovascular death and HF hospitalization by 20% vs enalapril
• Use when: Transitioning from ACEi/ARB to ARNi

DAPA-HF (2019) & EMPEROR-Reduced (2020)

• SGLT2 inhibitors reduce cardiovascular death and HF hospitalization in HFrEF
• Benefit independent of diabetes status
• Use when: Initiating SGLT2i in any HFrEF patient

RALES (1999) & EMPHASIS-HF (2011)

• Mineralocorticoid antagonists reduce mortality in HFrEF
• Use when: Documenting MRA indication

COPERNICUS (2001) & MERIT-HF (1999)

• Beta-blockers reduce mortality in stable HFrEF
• Use when: Discussing beta-blocker optimization

For Device Therapy

MADIT-II, SCD-HeFT

• ICD indication: EF ≤35% despite 3+ months of GDMT
• Document: “Will reassess EF after GDMT optimization for ICD candidacy per MADIT-II criteria”

COMPANION, MADIT-CRT

• CRT indication: EF ≤35% + LBBB + QRS ≥150ms
• Document: “QRS 156 ms with LBBB morphology. Will evaluate for CRT-D given criteria met”

Documentation Tips

Be Specific About Diuretic Response

Avoid writing “continue diuretics.” Document:

• Current diuretic regimen with doses
• Response to diuresis (urine output, weight change)
• Goal output and weight
• Plan for adjustment

“Furosemide 80 mg IV BID with UOP 2.5 L over 24 hours and weight down 1.8 kg. Goal UOP 3-4 L daily until reaching dry weight of 93.7 kg. Will continue current dose; reassess tomorrow for dose adjustment.”

Document Discharge Planning Early

This supports appropriate length of stay and transitions of care:

“Discharge planning: Target euvolemia before transition to oral diuretics. Will need outpatient cardiology follow-up within 7 days (per OPTIMIZE-HF data showing reduced readmissions). Medication reconciliation with pharmacy for GDMT optimization. Referral to HF clinic if recurrent admissions.”

Use Standardized Language

Consistent terminology helps with quality metrics and data extraction:

• “Acute decompensated heart failure” (not “CHF flare”)
• “Guideline-directed medical therapy” (not “max medical therapy”)
• “Volume overloaded” (not “wet”)
• “Euvolemic” (not “dry”)

Common Pitfalls to Avoid

1. Not documenting EF with every admission - Reference most recent EF with date
2. Forgetting to specify acute vs chronic - “Acute on chronic” captures the exacerbation
3. Omitting NYHA class - Takes seconds to document, impacts coding
4. Not explaining GDMT gaps - If not on a medication class, explain why
5. Vague volume status - Quantify findings when possible

Putting It All Together

A complete CHF A&P integrates these elements into a cohesive narrative demonstrating clinical reasoning, evidence-based care, and accurate severity documentation.

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