• Document site:
  • tubal
  • ovarian
  • abdominal
  • specify other
• Document complications such as:
  • Damage to pelvic organs
  • Embolism (and type: amniotic vs blood vs air)
  • Hemorrhage (delayed vs excessive)
  • Infection (pelvic )
  • Sepsis
  • Shock
  • Other

Adult (main)| . . .

Read More

• Document site and type:
  • Cervix: mild, moderate, severe
  • Vaginal: mild, moderate, severe
  • Vulva: mild, moderate, severe

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

Please enter . . .

Read More

• Document type, such as:
  • Postpartum or post-natal
  • If pre-existing, document type. Unspecified depression diagnosis is coded as major depression. If not major depression, please specify type of depression:
    • Adjustment disorder with or without depression and/or anxiety (e.g., grief reaction)
    • Anxiety . . .

Read More

• Document type of abortion
  • missed abortion
  • spontaneous
  • therapeutic
  • complete or incomplete
  • blighted ovum
• Document complication such as:
  • hemorrhage, delayed, excessive
  • infection
  • shock
  • sepsis
  • renal failure
  • embolism (and type: amniotic vs blood vs air)
  • other type
  . . .

Read More

Etiology:

• Excess calories
• Drug-induced

• Familial

  • Thyroid disorder
  • Pituitary disorder

• Document if the patient is obese or morbidly obese

• Document body-mass index

• Document if patient has alveolar hypoventilation syndrome

Adult (main)|Pediatrics (main)

Thanks to . . .

Read More

• Type: protein calorie or protein energy
• Severity: mild (1st degree), moderate (2nd degree), severe (3rd degree). Avoid range of severity [ e.g., moderate-to-severe]).
• Document Body-mass index

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for . . .

Read More