Advocate Physician Informatics

Cataracts

Improving Physician Documentation Specificity

  • Document type
    • age-related
    • Incipient
    • Cortical
    • Anterior or posterior subcapsular polar
    • Nuclear
    • Morgagnian or
    • Combined forms
  • Document other types of cataracts
    • Drug induced-list the specific drug: prednisone, thorazine
    • Secondary to eye trauma-identify the circumstances: . . .

Read More

June 01, 2015

Blindness and Visual Impairment

Improving Physician Documentation Specificity

Document blindness and visual impairment for each eye when known

  • normal vision
  • low vision
  • blindness
  • blindness both eyes
  • blindness, one eye, low vision other eye, unspecified eyes
  • low vision, right eye, normal vision left eye

Adult (main)|Pediatrics (main)

Thanks to Advocate's . . .

Read More

June 01, 2015

Subdural hemorrhage

Improving Physician Documentation Specificity

  • Document type: Acute, Subacute, or Chronic
  • Document Non-Traumatic vs Traumatic
  • Document if with loss of consciousness and for how long in minutes

Adult (main)|Pediatrics (main)

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

. . .

Read More

June 01, 2015

Sleep Apnea

Improving Physician Documentation Specificity

Document type

  • Central sleep apnea
  • Obstructive
  • Congenital central alveolar hypoventilation

Adult (main)|Pediatrics (main)

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

Please enter your comments below for us to update . . .

Read More

June 01, 2015

Seizures

Improving Physician Documentation Specificity

Link to underlying cause
Examples: Febrile, alcoholic, recurrent, post-traumatic, neoplasm

Adult (main)|Pediatrics (main)

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

Please enter your comments below for us to update this information based . . .

Read More

June 01, 2015

Phantom Limb Syndrome

Improving Physician Documentation Specificity

Document With or without pain
Adult (main)|Pediatrics (main)

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

Please enter your comments below for us to update this information based on your feedback.

Read More

June 01, 2015

Pain syndrome

Improving Physician Documentation Specificity

Document "central pain syndrome" or "chronic pain syndrome."
Chronic Pain syndrome is not equivalent to Chronic Pain

Adult (main)|Pediatrics (main)

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

Please enter your comments . . .

Read More

June 01, 2015

Archive

This update link alerts you to new Silvrback admin blog posts. A green bubble beside the link indicates a new post. Click the link to the admin blog and the bubble disappears.

Got It!