Advocate Physician Informatics

Meningitis

Improving Physician Documentation Specificity

Document

  • Type (bacterial, viral or other)
  • Causative organism, when known or suspected
    • Viral: adenovirus, enterovirus, chickenpox, measles, etc.
    • Bacterial: Escherichia coli,Klebsiella, Staphylococcus aureus, Streptococcus, gram-negative bacteria, etc.
    • Fungal
    • Other: nonpyogenic, chronic, benign . . .

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May 30, 2015

Intestinal infectious disease

Improving Physician Documentation Specificity

Document type: Bacterial, Viral
Document causative organism, when known or suspected

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 . . .

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May 30, 2015

Influenza

Improving Physician Documentation Specificity

  • Document identified influenza virus
    • Influenza A
    • Novel Influenza A
    • Other types of Influenza A
  • Document respiratory manifestation
    • pneumonia
    • lung abscess
    • laryngitis
    • pharyngitis
  • Other manifestations
    • myocarditis
    • encephalopathy
    • otitis manifestation
    • . . .

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May 30, 2015

Herpes simplex

Improving Physician Documentation Specificity

Document if these conditions are present

  • Eczema herpeticum
  • Herpesviral vesicular dermatitis
    • Herpes simplex facialis
    • Herpes simplex labialis
    • Vesicular dermatitis of ear or lip
  • Herpesviral gingostomatitis and pharyngotonsilitis
  • Herpesviral meningitis
  • Herpesviral encephalitis
  • Simian B . . .

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May 30, 2015

Hepatitis viral

Improving Physician Documentation Specificity

Document

  • Etiology
    • Alcoholic
    • Drug (specify)
    • Viral (A, B, C or E). For patients with hepatitis B, is the delta agent present?
  • Acute or chronic
  • Is hepatic coma present?

Adult (main)|Pediatrics (main)

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

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May 30, 2015

Drug Resistant Infection

Improving Physician Documentation Specificity

Document all infections that are drug resistant.
Document name of drug they are resistant to

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 . . .

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May 30, 2015

AIDS

Improving Physician Documentation Specificity

  • Document HIV positive when patient has not progressed to AIDS
  • AIDS or symptomatic HIV infection means the patient has in the past or is currently showing signs of the infection
  • Identify all conditions related to AIDS: Pneumocystis pneumonia, Kaposi sarcoma

Adult (main)|Pediatrics (main)

Thanks to . . .

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May 30, 2015

Archive

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