Respiratory
Improving Physician Clinical Documentation
Acidosis (lactic, metabolic, respiratory): link abnormal lab value to clinical diagnosis
Asthma
Bronchitis
COPD
Emphysema
Influenza
Malnutrition
Lung cancer
Obesity
Pleural effusion: If pleural effusion is malignant, link neoplasm to the pleural effusion.
Pneumonia/pneumonitis
Pneumothorax
. . .
Ear, nose and throat
Improving Physician Documentation Specificity
Eustachian tube dysfunction
Hearing loss
Inner ear disease
Mastoiditis
Otitis externa
Otitis media
Rhinitis
Ruptured tympanic membrane
Sinusitis
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
. . .Ophthalmology
Improving Physician Documentation Specificity
Blindness and visual impairment
Cataracts
Complications of eye surgery
Diabetic eye disease
Eye disease caused by other diseases - document underlying condition (e.g., cataract due to hypoparathyroidism, glaucoma due to amyloidosis)
Glaucoma
Retained foreign body in the eye
Retinal detachment - document type (e.g., . . .
Nervous system
Improving Physician Documentation Specificity
Musculoskeletal
Improving Physician Documentation Specificity
Intervertebral disc disorder
Osteoarthritis
Osteoporosis
Pathologic fractures
Rheumatoid arthritis
Spinal column injury or disease
Spinal cord injury
Spondylosis
Sprain
Traumatic fractures
Vertebral fracture
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation . . .
Mental/Behavioral health
Improving Physician Documentation Specificity
Alcohol/Drug abuse and dependence
Alzheimer's disease
Bipolar disorder
Depression (click here for post-partum depression)
-Major depression
Dementia
Eating disorder
Gender identity disorder
Post-traumatic stress disorder - acute or chronic
Reactive attachment disorder of childhood - document any . . .
Infectious diseases
Improving Physician Documentation Specificity
AIDS
Central-line bloodstream infection
Cystitis
Drug-resistant infection - Document all infections that are drug resistant and identify the drug(s). (e.g., MRSA, MSSA, VRE).
Hepatitis, viral
Influenza
Intestinal infectious disease- Document type or causative organism when known or suspected (e.g., bacterial, viral, . . .