Seizures
Improving Physician Documentation Specificity
Link to underlying cause (e.g., febrile, alcoholic, recurrent, post-traumatic, neoplasm).
Adult (main)|Pediatrics (main)
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Fever
Improving Physician Documentation Specificity
Link to underlying cause (e.g., infection).
Adult (main)|Pediatrics (main)
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Encephalopathy
Improving Physician Documentation Specificity
- Document the specific type of encephalopathy
- Encephalopathy is the generalized alteration in brain function due to an underlying cause EXCEPT trauma. Common etiologies include:
- Toxins: Chemotherapy, Steroids, or Transplant complication
- Metabolic: Uremic, Hyper- or hyponatremic
- Toxic: Metabolic
- Septic: . . .
Hypotension
Improving Physician Documentation Specificity
Document specific types:
- Idiopathic
- Orthostatic
- Postural
- Medication-related: specify drug
- Post procedural
- Due to hemodialysis
- Chronic
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
. . .Dizziness and vertigo
Improving Physician Documentation Specificity
Link to underlying cause (e.g., Meniere’s, vestibular, carotid stenosis, arrhythmia, neurologic).
Adult (main)|Pediatrics (main)
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Chest Pain
Improving Physician Documentation Specificity
Link to underlying cause (e.g., GERD, anxiety, coronary artery disease, unstable angina).
Adult (main)|Pediatrics (main)
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Altered Mental Status
Improving Physician Documentation Specificity
- Link to underlying cause. For example:
- Adverse effect of medication
- Alcohol
- Encephalopathy
- Infectious (UTI)
- Neurologic (stroke)
- Poisoning
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this . . .