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 . . .
Intestinal infectious disease
Improving Physician Documentation Specificity
Document type: Bacterial, Viral
Document causative organism, when known or suspected
Adult (main)|Pediatrics (main)
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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
- . . .
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 . . .
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 . . .
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 . . .
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)
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