Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
Spinal Cord Injury
Improving Physician Documentation Specificity
- Document site of injury:
- Specific vertebral segment injured, for example, L3
- Document type of injury, for example:
- Compression and edema
- Complete lesion
- Incomplete Lesion with central or anterior cord syndrome
- Brown-Sequard’s paralysis syndrome
- Document associated plegia and/or . . .
May 18, 2015
Spinal Column Injury or Disease
Improving Physician Documentation Specificity
For conditions of the spinal column, document site affected as:
- Occipito-atlanto-axial
- Cervical or cervical-thoracic
- Thoracic or thoracolumbar
- Lumbar or lumbosacral
- Sacral or sacrococcygeal
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding . . .
May 18, 2015
Pathologic fractures
Improving Physician Documentation Specificity
- Specify whether etiology is:
- Osteoporosis (senile vs. disuse)
- Osteopenia
- Neoplastic- Document neoplasm linked to fracture.
- Some other disease
- Document site and laterality.
- If compression fracture, clarify if traumatic or pathological.
Adult (main)|Pediatrics (main)
Thanks to . . .
May 18, 2015
Osteoporosis
Improving Physician Documentation Specificity
Document etiology, for example:
- Post-menopausal
- Drug induced
- Post-traumatic
- Senile/Disuse
Is current osteoporotic fracture present?
- If present, document site of fracture and laterality.
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical . . .
May 18, 2015
Osteoarthritis
Improving Physician Documentation Specificity
Document type, for example:
- Primary
- Posttraumatic
- Other Secondary
Document site, for example:
- Hip
- Knee
- Shoulder
Document laterality, for example:
- Right
- Left
- Bilateral
Adult (main)|Pediatrics (main)
Thanks to Advocate's . . .
May 18, 2015
Intervertebral disc disorder
Improving Physician Documentation Specificity
Document site as:
- Cervical
- Thoracic
- Lumbar
- Sacral
- Other
Document any associated:
- Disc Displacement
- Disc Degeneration
- Myelopathy
- Radiculopathy
- Sciatica
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement . . .
May 18, 2015
Skin
Improving Physician Documentation Specificity
Document site and laterality
- Lower leg
- Foot
- Heel
If non-pressure ulcer
- Document type
- Non-healing
- Chronic
- Stasis
- Diabetic
- Atherosclerotic
- Document associated infection or gangrene
If pressure ulcer (decubitus)
- Document if . . .
May 16, 2015
