R00.2 - Palpitations

Clinical Definition

Acute upper respiratory infection is a condition affecting the upper airways (nose, sinuses, pharynx, larynx) characterized by inflammation and congestion, typically viral in nature and self-limiting within 10-14 days.

Documentation Requirements

• Duration: Must specify "acute" vs chronic

• Location: Document specific anatomical sites involved (e.g., nose, throat)

• Symptoms: List presenting symptoms:

  • Rhinorrhea

  • Cough

  • Sore throat

  • Fever (if present)

• Cause: Document if known viral/bacterial etiology

• Associated conditions: Note any comorbidities like asthma exacerbation

Common Synonyms

• Common cold

• Head cold

• Upper respiratory infection (URI)

• Viral syndrome

• "The crud"

Coding Conflicts

Excludes1:

• Influenza

• Strep throat

• Specific viral infections (e.g., COVID-19)

Excludes2:

• Chronic sinusitis

• Allergic rhinitis

Scribing.io Automation

The AI scribe automatically:

• Identifies symptoms consistent with URI pattern

• Tags "acute" temporal references

• Maps anatomical descriptions to upper respiratory tract

• Flags conflicting diagnoses (like influenza or COVID)

• Captures symptom duration for acuity verification