Advocate Physician Informatics

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

All Categories: support(1) chf(1) congestive heart failure(1) cardiac(1) fluid overload(1) i10(1) medical directors of clinical informatics(1) pc touch(1) cdi(1) documentation(1) home

Vesicoureteral Reflux

Improving Physician Documentation Specificity

Document if with: Nephropathy (and hydroureter), Congenital, Pyelonephritis (and causative organism)
Document unilateral or bilateral

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 28, 2015

Pyelonephritis

Improving Physician Documentation Specificity

Document acuity and laterality: Acute/Chronic, Right/Left
Document if present with: Calculus, Hydronephrosis
In patients with chronic indwelling catheter, please document if the pyelonephritis could be due to/or is related to indwelling catheter.

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical . . .

May 28, 2015

Nephrotic syndrome

Improving Physician Documentation Specificity

Document manifestation:
- glomerular lesions
- type glomerular nephritis

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 28, 2015

Nephritic syndrome

Improving Physician Documentation Specificity

Document severity: acute,rapidly progressive, or chronic
Document manifestation: glomerular disease, glomerular nephritis

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 28, 2015

Erectile dysfunction, male

Improving Physician Documentation Specificity

Document cause, such as:
* Vasculogenic
* Due to arterial insufficiency
* Due to corporo-venous occlusive disease
* Due to a combination of both of the above
* Due to other disease, for example, diabetes
* Drug-induced
* Post-surgical
* Due to simple/radical prostatectomy
* Due to radical . . .

May 28, 2015

Cystitis

Improving Physician Documentation Specificity

Document any presence of hematuria
Document type, such as:
- Acute
- Chronic
- Interstitial
- Trigonitis
Document causative organism, when known or suspected, such as E. coli or Candida.

Adult (main)|Pediatrics (main)

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

May 28, 2015

Chronic Kidney Disease (CKD)

Improving Physician Documentation Specificity

Chronic kidney disease (CKD) – document etiology, when known (e.g., diabetes, hypertension)
- Stage 1 CKD – GFR > 90 ml/min/1.73 m2
- Stage 2 CKD – GFR 60-90 ml/min/1.73 m2
- Stage 3 CKD – GFR 30-59 ml/min/1.73 m2
- Stage 4 CKD – GFR 15-29 ml/min/1.73 m2
- Stage 5 CKD – GFR <15 ml/min/1.73 m2
End-stage . . .

May 28, 2015

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