Advocate Physician Informatics

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

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Intracerebral or subarachnoid hemorrhage

Improving Physician Documentation Specificity

For Intracerebral Hemorrhage, document site as:
- Hemisphere
- Cerebellum (left or right)
- Subcortical
- Intraventricular
- Cortical
- Multiple sites
- Brain stem
- Other
For Subarachnoid Hemorrhage, document site and laterality when appropriate, such as:
- Carotid siphon and bifurcation

May 24, 2015

Cerebral Infarction/ Stroke

Improving Physician Documentation Specificity

Document etiology: due to embolus, thrombus
Document specific artery affected and right or left when appropriate:
- Vertebral -Middle
- Basilar -Anterior
- Carotid -Posterior
- Other
Document residuals from current stroke: hemiplegia/hemiparesis, dysphagia, cognitive defects
Document if TPA given at . . .

May 24, 2015

Cerebral Edema

Improving Physician Documentation Specificity

Link diagnostic study to clinical diagnosis
CT findings are not equivalent to a diagnosis

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 24, 2015

Brain Compression

Improving Physician Documentation Specificity

Link diagnostic study to clinical diagnosis
CT findings are not equivalent to a diagnosis
Midline shift is not equivalent to brain compression

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 24, 2015

Arterial Embolism and Thrombosis and Athero- embolism

Improving Physician Documentation Specificity

Document site:
- Aorta
- Upper/lower extremity
- Iliac artery
- Other specified artery
Document if septic with underlying cause.

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

. . .

May 24, 2015

Aneurysm

Improving Physician Documentation Specificity

Document site:
- Aorta, thoracic, abdomen
- Upper extremity
- Renal
- Iliac
- Lower extremity
- Other specified artery
Document with or without : Rupture, Dissection

Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their . . .

May 24, 2015

Peptic ulcer disease

Improving Physician Documentation Specificity

Document severity: acute, chronic
Document site: duodenal, esophagus, gastric, other
Document underlying cause: alcohol, drug or chemical
Document if associated with:
- Perforation
- Hemorrhage
- Perforation and hemorrhage

Adult (main)|Pediatrics (main)

Thanks to Advocate's . . .

May 20, 2015

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