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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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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Irritable bowel syndrome
Improving Physician Documentation Specificity
Document if with diarrhea
Document if psychogenic
Adult (main)|Pediatrics (main)
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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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Hernia
Improving Physician Documentation Specificity
- Document site:
- Diaphragmatic/Hiatal hernia
- Inguinal hernia with laterality
- Femoral hernia
- Umbilical hernia
- Ventral hernia
- Diaphragmatic/Hiatal hernia
- Document if with:
- Gangrene
- Obstruction ( e.g., strangulated or irreducible)
- Gangrene and obstruction
Adult (main)|Pediatrics (main)
. . .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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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)
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