Adult Physician Documentation Improvement Table of Contents (Emergency Medicine)
Improving physician documentation specificity
- In general, medical coding can be drawn from documentation from any healthcare provider (consultants, residents, nurse practitioners, physician assistants, etc.).
Consider the following dimensions when documenting a patient's conditions:
- Where (site and laterality)
- Specificity (the most detailed diagnosis to match the patient’s condition)
- Timing (acute or chronic)
- Manifestations
- Stage, and
- Status (e.g., new, unchanged, improving, resolving)
Link abnormal laboratory or imaging results to the underlying cause (e.g., hyponatremia is due to the patient's hepatic failure).
Whenever possible, attribute a patient's clinical presentation to an underlying condition (e.g., the patient's shortness of breath is due to ...)
| Top Emergency | Room Diagnoses |
|---|---|
| Abdominal pain | Malnutrition |
| Shortness of breath | Obesity |
| Chest pain | Phlebitis |
| Coma | Renal failure |
| Deep vein thrombosis | Shock, hypotension |
| GI hemorrhage (anemia) | SIRS and sepsis |
| Heart failure | Thrombophlebitis |
| Hypernatremia | Urinary retention |
| Hypokalemia |
More about adult patients|More about pediatric patients
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
Please enter your comments below for us to update this table of contents based on your feedback.
Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
