Cataracts
Improving Physician Documentation Specificity
- Document type
- age-related
- Incipient
- Cortical
- Anterior or posterior subcapsular polar
- Nuclear
- Morgagnian or
- Combined forms
- Document other types of cataracts
- Drug induced-list the specific drug: prednisone, thorazine
- Secondary to eye trauma-identify the circumstances: . . .
Blindness and Visual Impairment
Improving Physician Documentation Specificity
Document blindness and visual impairment for each eye when known
- normal vision
- low vision
- blindness
- blindness both eyes
- blindness, one eye, low vision other eye, unspecified eyes
- low vision, right eye, normal vision left eye
Adult (main)|Pediatrics (main)
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Subdural hemorrhage
Improving Physician Documentation Specificity
- Document type: Acute, Subacute, or Chronic
- Document Non-Traumatic vs Traumatic
- Document if with loss of consciousness and for how long in minutes
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
. . .
Sleep Apnea
Improving Physician Documentation Specificity
Document type
- Central sleep apnea
- Obstructive
- Congenital central alveolar hypoventilation
Adult (main)|Pediatrics (main)
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Seizures
Improving Physician Documentation Specificity
Link to underlying cause
Examples: Febrile, alcoholic, recurrent, post-traumatic, neoplasm
Adult (main)|Pediatrics (main)
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Phantom Limb Syndrome
Improving Physician Documentation Specificity
Document With or without pain
Adult (main)|Pediatrics (main)
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Pain syndrome
Improving Physician Documentation Specificity
Document "central pain syndrome" or "chronic pain syndrome."
Chronic Pain syndrome is not equivalent to Chronic Pain
Adult (main)|Pediatrics (main)
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