Advocate Physician Informatics

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

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Depression

Improving Physician Documentation Specificity

An unspecified depression diagnosis is coded as major depression.

Document type, such as:
- Adjustment disorder with or without depression and/or anxiety, (e.g., grief reaction)
- Anxiety depression
- Depressive neurosis
- Major depression

Adult (main)|Pediatrics (main)

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May 31, 2015

Bipolar Disorder

Improving Physician Documentation Specificity

Document current episode as: Hypomanic, Manic, Depressed, or Mixed
If current episode is manic or depressed, document
- Mild, moderate, or severe
- With or without psychotic features
If patient is in remission, document:
- Full versus partial remission
- Most recent episode as hypomanic, manic, . . .

May 31, 2015

Alcohol/ Drug Abuse and Dependence

Improving Physician Documentation Specificity

Document specific drug used/abused
Frequency (use, abuse, dependence, in remission)
State “no related complications,” when applicable
Specify intoxication/withdrawal as “uncomplicated” or “with delirium"
Document any related mood disorder (anxiety or delirium)
Document any delusions, hallucinations, psychotic . . .

May 31, 2015

Typhoid and Paratyphoid Fever

Improving Physician Documentation Specificity

For typhoid fever, document any associated complications, such as: Pneumonitis, Meningitis
For paratyphoid fever, document type as: Type A, B, or C

Adult (main)|Pediatrics (main)

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

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May 31, 2015

Tuberculosis

Improving Physician Documentation Specificity

Document severity: Acute, Chronic
Document site: Respiratory (lung, larynx, trachea, etc.), Nervous system (meninges, brain, spinal cord, etc.)

Adult (main)|Pediatrics (main)

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

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May 31, 2015

Staphylococcus aureus

Improving Physician Documentation Specificity

Document if methicillin-resistant (MRSA) or methicillin-sensitive (MSSA)
Document if septic shock is present

Adult (main)|Pediatrics (main)

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

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May 31, 2015

Sepsis

Improving Physician Documentation Specificity

Sepsis

Document your intended diagnosis by distinguishing between sepsis, septicemia, or severe sepsis
Document underlying infection when known
Do not use sepsis syndrome

Severe sepsis

Document septic shock, when present.
Document any associated organ dysfunction (e.g., acute kidney . . .

May 30, 2015

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