Advocate Physician Informatics

Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.

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Cerebral Infarction/ Stroke

Improving Physician Documentation Specificity

Document etiology:
- Due to embolus
- Due to thrombus
Document specific precerebral or cerebral artery affected and right or left when appropriate:
- Vertebral
- Basilar
- Carotid
- Middle
- Anterior
- Posterior
- Other
Document residuals from current stroke. For example: . . .

May 31, 2015

Brain Compression

Improving Physician Documentation Specificity

Link diagnostic study to clinical diagnosis
CT findings are not equivalent to a diagnosis
Documentation of Midline shift is not equivalent to brain compression

Adult (main)|Pediatrics (main)

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

. . .

May 31, 2015

Alzheimer’s Disease

Improving Physician Documentation Specificity

Document onset as: Early or Late
If with dementia, document as:
- With behavioral disturbance, for example combative and/or aggressive behavior or wandering
- Without behavioral disturbance

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding . . .

May 31, 2015

Schizophrenia

Improving Physician Documentation Specificity

Document type:
- Catatonic
- Paranoid
- Disorganized
- Residual
- Other
- Undifferentiated
If diagnosis is schizoaffective disorder, document type as: Bipolar or Depressive

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for . . .

May 31, 2015

Gender identity disorder

Improving Physician Documentation Specificity

Document: In adolescence or adulthood
State any sex reassignment status

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.

. . .

May 31, 2015

Eating Disorder

Improving Physician Documentation Specificity

Specify Type

Anorexia nervosa-restricting type
Anorexia nervosa-binge eating type
Anorexia nervosa-purging type
Bulimia nervosa
PICA
Psychogenic loss of appetite

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their . . .

May 31, 2015

Depression, postpartum

Improving Physician Documentation Specificity

Document type, such as:
- Major depression
- Adjustment disorder with or without depression and/or anxiety, e.g., grief reaction
- Anxiety depression
- Depressive neurosis
- Unspecified depression diagnosis is coded as major depression

Adult (main)|Pediatrics (main)

Thanks to Advocate's . . .

May 31, 2015

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