• Document onset (acute, chronic, acute on chronic)
• Document type (hypoxic, hypercapneic, hypoxic and hypercapneic)
• Document underlying cause (e.g., COPD)
• If post-procedural, distinguish between acute and acute on chronic post-procedural respiratory failure

Adult (main)|Pediatrics (main)

Thanks to . . .

Read More

• Document acute or chronic.
• Document cause
  • Newborn
  • Shock
  • Surgery (thoracic versus non-thoracic)
  • Trauma

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

Please enter your . . .

Read More

• Document if present on admission
• Document type:
  • Chronic
  • Post-procedural
  • Spontaneous (i.e., primary, secondary, tension)
  • Traumatic

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

. . .

Read More

• Document each site and its laterality
• Document size and depth of lacerations
• Document type of closure(s) (e.g., simple, intermediate, complex)

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

Please . . .

Read More

• Document site
  • Brain stem
  • Left or right cerebrum
  • Cerebellum
  • Epidural
  • Subarachnoid
  • Subdural
  • Other
• Document traumatic or non-traumatic
• If with loss of consciousness, document for how long in minutes

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical . . .

Read More

• Anatomic site (e.g., elbow, trunk, shoulder, etc.) and laterality (i.e., right or left)
• Degree of the burn (i.e., first, second, or third)
• Burn type (e.g., thermal, radiation, electric, corrosive [by chemicals], etc.) and substance causing the injury (e.g., fire, gasoline, bleach, hot toaster oven, hot water, etc.)
• Extent of . . .

Read More