Advocate Physician Informatics

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
. . .

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May 16, 2015

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.

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May 16, 2015

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., . . .

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May 16, 2015

Nervous system

Improving Physician Documentation Specificity

Alzheimer's disease
Brain compression
Brain hemorrhage
Cerebral infarction/stroke
Cerebrovascular disease sequelae
Dementia
Diabetic neuropathy
Encephalopathy
Epilepsy
Intervertebral disc disorder
Intracerebral or subarachnoid hemorrhage
Meningitis
Migraines
Pain
Seizures Link to . . .

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May 16, 2015

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 . . .

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May 16, 2015

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 . . .

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May 16, 2015

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, . . .

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May 16, 2015

Archive

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