Advocate Physician Informatics

Seizures

Improving Physician Documentation Specificity

Link to underlying cause (e.g., febrile, alcoholic, recurrent, post-traumatic, 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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May 27, 2015

Fever

Improving Physician Documentation Specificity

Link to underlying cause (e.g., infection).

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 27, 2015

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: . . .

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May 27, 2015

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.

. . .

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May 27, 2015

Dizziness and vertigo

Improving Physician Documentation Specificity

Link to underlying cause (e.g., Meniere’s, vestibular, carotid stenosis, arrhythmia, neurologic).

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 . . .

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May 27, 2015

Chest Pain

Improving Physician Documentation Specificity

Link to underlying cause (e.g., GERD, anxiety, coronary artery disease, unstable angina).

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 . . .

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May 27, 2015

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 . . .

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May 27, 2015

Archive

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