Medical Directors of Clinical Informatics May 2015
May 14, 2015, 0730-0830 hours
Attendees | ||
---|---|---|
Richard Baker (Good Shepherd) | Christopher Jamerson (Park Ridge) | Kent Nelson (Oak Lawn) |
James Ferrel (Christ) | Tahir Khokher (South Suburban) | Douglas Propp (Lutheran General) |
Anupam Goel (corporate) | Elliot Levine (Illinois Masonic) | Natalie Selk . . . |
Infectious Diseases (Pediatrics)
Improving Physician Documentation Specificity
Abscess
Antibiotic resistant infections (including Methicillin Resistant Staphylococcus Aureus infections)
Catheter associated urinary tract infections
Cellulitis
Central line associated bloodstream infections
HIV
Influenza
Kawasaki's syndrome
Osteomyelitis
Pyelonephritis
Sepsis
Sepsis of the . . .
Ophthalmology (Pediatrics)
Improving Physician Documentation Specificity
Corneal abrasion
Retinal detachment
Conjunctivitis
Retinopathy of prematurity (ROP)
Foreign body
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Diverticulitis
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 . . .
Crohn’s Disease, Diverticulitis & 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 . . .
Barrett’s Esophagus
Improving Physician Documentation Specificity
Document when present: Low grade dyplasia, High grade dysplasia
Adult (main)|Pediatrics (main)
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Appendicitis
Improving Physician Documentation Specificity
- Document severity:
- Acute
- Chronic
- Recurrent
- Relapsing
- Subacute
- Document if with:
- Peritoneal abscess
- Peritonitis
- Gangrene
- Perforation
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for . . .