Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
Abdominal Pain
Improving Physician Documentation Specificity
- Link symptoms to clinical diagnosis:
- Small bowel obstruction
- Pancreatitis: acute vs chronic
- Peptic Ulcer Disease
- Pelvic Inflammatory Disease
- Gastroenteritis
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their . . .
May 18, 2015
Sinusitis
Improving Physician Documentation Specificity
- Document severity:
- Acute
- Chronic
- Recurrent
- Document location:
- Ethmoid
- Frontal
- Maxillary
- Pansinusitis
- Sphenoid
- Note that a diagnosis of sinusitis is coded as chronic sinusitis. If your intended diagnosis is acute sinusitis, you must document acute.
May 18, 2015
Rhinitis
Improving Physician Documentation Specificity
Document severity:
- Acute
- Chronic
- Allergic
- Vasomotor
Note that a diagnosis of rhinitis is coded as chronic rhinitis. If your intended diagnosis is acute rhinitis, you must document acute .
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement . . .
May 18, 2015
Vertebral fractures
Improving Physician Documentation Specificity
- Document:
- Level of vertebral column, for example, L1
- Displaced versus nondisplaced
- Part of vertebra fractured, for example, posterior arch
- Document type of fracture, for example:
- Type II dens fracture of the 2nd cervical vertebra
- Type III spondylolisthesis of the 2nd cervical vertebra . . .
May 18, 2015
Traumatic fractures
Improving Physician Documentation Specificity
- Document:
- Name of specific bone and specific site on bone
- Displaced versus nondisplaced
- Open versus closed. For open fractures of the forearm, femur, and lower leg, document type by Gustilo classification (Type I, II, IIIA, IIIB, or IIIC)
- Orientation of fractures, such as transverse, oblique, spiral
- . . .
May 18, 2015
Sprain
Improving Physician Documentation Specificity
- Document site and laterality, for example:
- Ankle
- Wrist
- Shoulder
- Neck
- Document ligament affected, for example:
- Calcaneofibular
- Deltoid
- Carpal
- Acromioclavicular
- Rotator Cuff
- Document cause:
- Fall
- Overuse
May 18, 2015
Spondylosis
Improving Physician Documentation Specificity
- Document by type:
- Anterior spinal artery compression syndrome
- Vertebral artery compression syndrome
- Other spondylosis
- Document site as:
- Occipito-atlanto-axial
- Cervical or Cervical-thoracic
- Thoracic or Thoracolumbar
- Lumbar or Lumbosacral
- Sacral or Sacrococcygeal
- . . .
May 18, 2015
