Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
Genitourinary system
Improving Physician Documentation Specificity
Benign prostatic hypertrophy (BPH) - Document all associated urinary tract symptoms (e.g., BPH with urinary frequency & obstruction)
Bladder dysfunction - Document any associated urinary incontinence (e.g., neuromuscular bladder dysfunction with urge incontinence)
Cardiorenal syndrome/Hypertensive heart disease
Chronic kidney . . .
General symptoms
Improving Physician Documentation Specificity
Abdominal pain
Altered mental status
Chest pain - link to underlying cause (e.g., GERD, anxiety, coronary artery disease, unstable angina)
Dizziness and vertigo - link to underlying cause (e.g., Meniere's, vestibular, carotid stenosis, arrhythmia, neurologic)
Hypotension
Fever - link to underlying cause (e.g., . . .
Gastrointestinal
Improving Physician Documentation Specificity
Abdominal pain
Appendicitis
Barrett's esophagus - document when low grade or high grade dypslasia present
Crohn's disease, diverticulitis & diverticulosis
Gastritis
Gastroenteritis
Gastrointestinal bleed, hematemesis & melena
Hemorrhoids
Hepatic failure
Hepatitis
Hernia
Intestinal . . .
Gynecology
Improving Physician Documentation Specificity
Dysplasia
Endometriosis
Genital prolapse
Menstruation, excessive and frequent
Adult (main)|Pediatrics (main)
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Endocrine/metabolic
Improving Physician Documentation Specificity
Acidosis - specify if metabolic, respiratory or lactic. Link abnormal lab value to clinical diagnosis.
Diabetes
Gout
Malnutrition
Obesity
Adult (main)|Pediatrics (main)
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Circulatory, non-cardiac
Improving Physician Documentation Specificity
Aneurysm
Arterial embolism, thrombosis, atheroembolism
Brain compression
Cerebral edema
Cerebral infarction/stroke
Hypotension
Intracerebral or subarachnoid hemorrhage
Subdural hemorrhage
Occulsion and stenosis of pre-cerebral artery
Occlusion and stenosis of cerebral artery
Peripheral vascular disease
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Oncology
Improving Physician Documentation Specificity
- Anatomic site and laterality (e.g., lung, prostate, kidney, breast, colon)
- Benign, malignant, or unspecified behavior
- Document the primary site if primary cancer still present.
- For secondary or metastatic sites, document each individual site.
- Is treatment still being provided for primary and/or metastatic site?
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