Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
Hemorrhoids
Improving Physician Documentation Specificity
- In addition to internal or external hemorrhoids that may be thrombosed, use current terminology to describe hemorrhoids:
- First degree or grade/stage 1 - without prolapse outside of anal canal
- Second degree or grade/stage 2 - prolapse with straining, but retracts spontaneously
- Third degree or grade/stage 3 - prolapse . . .
Gastrointestinal bleed, hematemesis & melena
Improving Physician Documentation Specificity
Document etiology and show cause and effect, for example, acute GI bleed due to:
- Angiodysplasia
- Arteriovenous malformation
- Bleeding esophageal varices
- Gastritis
- Hemorrhoids
- Tumor
- Ulcers
- Unable to determine source of acute GI bleed
Document where blood was found: rectal, hematochezia, . . .
Gastroenteritis
Improving Physician Documentation Specificity
Document etiology when known or suspected: Infectious, Non-infectious
If infectious, document organism when known or suspected
If non-infectious, document cause, such as:
- Radiation or drug induced, specify drug when known
- Allergic or food hypersensitivity, specify food when known
Adult (main)| . . .
Gastritis
Improving Physician Documentation Specificity
- Document severity: Acute, Chronic
- Document underlying cause:
- Alcohol induced
- Diet deficiency
- Viral
- Allergic
- Document associated complications: Bleeding
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their . . .
Diverticulosis
Improving Physician Documentation Specificity
- Document anatomical site:
- Large intestine
- Small intestine
- Small and Large Intestine
- Document any associated complications, such as:
- Bleeding
- Intestinal obstruction
- Fistula
- Abscess
- Perforation
- Don’t use the term “inflammatory bowel disease.” Use of this term when your . . .
Trauma (Pediatrics)
Improving Physician Documentation Specificity
Fall (inside or outside of hospital)
Head trauma
Non-accidental trauma
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
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Nervous (Pediatrics)
Improving Physician Documentation Specificity
Cerebral Infarction/Stroke
Concussion
Developmental Delay/Disorders
Headache
Hemorrhage, Brain (Intracerebral/Subarachnoid/Subdural)
Migraine
Seizures/Epilepsy
Spina bifida
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this . . .
