Adverse effects and poisoning
Improving physician documentation specificity
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
- Is this an adverse effect (e.g., side effect or sensitivity to a drug correctly administered) or is this a poisoning (e.g., misuse of drug like an overdose, combination of a medication with alcohol)?
- Supply the name of the substance causing the complications (e.g., Prednisone, shellfish, Digoxin, latex)
- List all complications the substances may have caused (e.g., cardiac arrest, convulsions, arrhythmias)
- Specify any abuse of or dependence on the substance
- Specify any external causes (e.g., malfunction of insulin pump)
- Provide information regarding the circumstances surrounding the event as follows:
- Accidental (i.e., unintentional)
- Intentional (i.e., self- harm)
- Assault
- Undetermined (when impossible to determine the intent)
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
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Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.