Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
Cardiorenal Syndrome, Hypertensive
Improving Physician Documentation Specificity
Document link of hypertension and cardiac and renal disease states
- Type 1 Cardio-Renal Syndrome: abrupt worsening of cardiac function leads to acute kidney injury (e.g., acute congestive heart failure causing acute kidney injury)
- Type 2 Cardio-Renal Syndrome: chronic worsening of cardiac function leads to chronic kidney . . .
Bladder Dysfunction
Improving Physician Documentation Specificity
- Document any associated urinary incontinence
- Neuromuscular bladder dysfunction with urge incontinence
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
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Benign Prostatic Hypertrophy (BPH)
Improving Physician Documentation Specificity
- Document all associated urinary tract symptoms
- BPH with urinary frequency & obstruction
Adult (main)|Pediatrics (main)
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Acute Kidney Failure/Injury
Improving Physician Documentation Specificity
Avoid AKI abbreviation. But if you still intend to use "AKI", specify if "AKI" means Acute Kidney Injury or Insufficiency. If "injury" is intended, but is not written at least once in the chart, it will code to the less severe diagnosis of "insufficiency".
- Document
- Etiology . . .
Syncope
Improving Physician Documentation Specificity
Link to underlying cause (e.g., arrhythmia, stroke, intracranial hemorrhage).
Adult (main)|Pediatrics (main)
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. . .Swelling
Improving Physician Documentation Specificity
Document site and laterality.
Link to underlying cause (e.g., traumatic injury, DVT, infection).
Adult (main)|Pediatrics (main)
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Shortness of Breath
Improving Physician Documentation Specificity
Link to underlying cause (e.g., COPD exacerbation, acute respiratory failure, lung disease, infectious source, pleural effusion, neoplasm).
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
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