Document type: Bacterial, Viral
Document causative organism, when known or suspected

Adult (main)|Pediatrics (main)

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• For Intracerebral Hemorrhage, document site as:
  • Hemisphere
  • Cerebellum
  • Subcortical
  • Intraventricular
  • Cortical
  • Multiple sites
  • Brain stem
  • Other
• For Subarachnoid Hemorrhage, document site and laterality when appropriate, such as:
  • Carotid siphon and bifurcation
  • Middle . . .

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• Document site as:
  • Cervical
  • Thoracic
  • Lumbar
  • Sacral
  • Other
• Document any associated:
  • Disc Displacement
  • Disc Degeneration
  • Myelopathy
  • Radiculopathy
  • Sciatica

Adult (main)|Pediatrics (main)

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• Document type and status
  • Intractable versus not intractable
  • With or without status epilepticus
• Specify type, for example:
  • Localization-related idiopathic or symptomatic
  • Simple partial or complex partial seizures
  • Generalized idiopathic
• Document if due to:
  • Alcohol
  . . .

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• Rather than “diabetic neuropathy,” if known or suspected, document instead:
  • Diabetic mononeuropathy
  • Diabetic polyneuropathy
  • Diabetic autonomic neuropathy
  • Diabetic amyotrophy
  • Other neurological complication
• Document type of diabetes such as Type 1, Type 2, or secondary
• If control is not . . .

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• Specify cause
  • Alzheimer
  • Vascular
  • Lewy bodies
  • Parkinsons
  • Arteriosclerotic
  • Alcoholic
• With or without behavior disturbance
  • Aggression
  • Combative behavior
  • Violent behavior
  • Wandering behavior

Adult (main)|Pediatrics (main)

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