• Document cause and effect relationship (e.g., dysphagia due to CVA, hemiplegia due to traumatic brain injury)
• Document underlying type of cerebrovascular disease (e.g., cerebral infarction/stroke, cerebral hemorrhage, traumatic brain injury, other)
• Document specific sequelae being treated
  • Cognitive defects
  • Speech (aphasia, dysphasia, dysarthria)
  • Fluency disorder
  • Monoplegia
  • Hemiplegia
  • Hemiparesis
• Document laterality and if the affected side is dominant or non-dominant
• Use paresis instead of weakness

Adult (main)|Pediatrics (main)

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

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