Advocate Physician Informatics

Pancreatitis

Improving Physician Documentation Specificity

  • Document acute, chronic, or acute on chronic.
  • Document etiology and show cause and effect, for example:
    • Idiopathic acute pancreatitis
    • Alcohol induced acute pancreatitis
    • Gallstones or biliary
    • Drug induced

Adult (main)|Pediatrics (main)

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May 20, 2015

Melena

Improving Physician Documentation Specificity

Link to underlying cause
Examples:Bleeding ulcer, bleeding hemorrhoids, colitis, Crohn’s

Adult (main)|Pediatrics (main)

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May 20, 2015

Irritable bowel syndrome

Improving Physician Documentation Specificity

Document if with diarrhea
Document if psychogenic

Adult (main)|Pediatrics (main)

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May 20, 2015

Intestinal infectious disease

Improving Physician Documentation Specificity

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

Adult (main)|Pediatrics (main)

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May 20, 2015

Hernia

Improving Physician Documentation Specificity

  • Document site:
    • Diaphragmatic/Hiatal hernia
    • Inguinal hernia with laterality
    • Femoral hernia
    • Umbilical hernia
    • Ventral hernia
  • Document if with:
    • Gangrene
    • Obstruction ( e.g., strangulated or irreducible)
    • Gangrene and obstruction

Adult (main)|Pediatrics (main)

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May 20, 2015

Hepatitis

Improving Physician Documentation Specificity

  • Document etiology:
    • Alcoholic
    • Drug (specify)
    • Viral (A, B, C or E). For patients with hepatitis B with or without delta agent.
  • Document if acute or chronic.
  • Document if hepatic coma present.

Adult (main)|Pediatrics (main)

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May 20, 2015

Hepatic failure

Improving Physician Documentation Specificity

  • Document type: Acute,Subacute, Chronic
  • Document if with hepatic coma.
  • Document etiology, for example, due to alcohol or drugs.

Adult (main)|Pediatrics (main)

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

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May 20, 2015

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