Advocate Physician Informatics
Increasing physician knowledge and proficiency with Advocate Health Care's clinical information systems.
Thrombocytopenia
Improving physician documentation specificity
Document if primary or secondary
If secondary, document underlying cause
* Idiopathic
* Congenital
* Heparin-induced
* Transient
Adult (main)|Pediatrics (main)
Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.
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March 17, 2015
Neutropenia
Improving physician documentation specificity
Document underlying cause
- Chemotherapy induced
- Congenital
- Drug induced
- Infection
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 . . .
March 17, 2015
Leukemia
Improving physician documentation specificity
- Onset: acute versus chronic
- Type (e.g., acute lymphoblastic, B-cell chronic lymphocytic, B-cell prolymphocytic, hairy cell, adult T-cell).
- Remission-relapse status for each encounter (e.g., not having achieved remission, in remission, in relapse).
March 17, 2015
Coagulopathy
Improving physician documentation specificity
Specify type
- Dissseminated intravascular coagulation
- Acquired coagulation factor deficiency
- Primary thrombophilia (e.g., Activated protein C resistance, prothrombin gene mutation, other primary thrombophilia)
- Other thrombophilia (e.g., Antiphospholipid syndrome, lupus anticoagulant syndrome)
- . . .
March 17, 2015
Anemia
Improving physician documentation specificity
- Document status: Acute, chronic or acute on chronic
- Link to underlying disease process
- Gastrointestinal
- Site, if known (e.g., stomach, duodenum, hemorrhoids)
- Etiology (e.g., inflammation, varices, ulcer, angiodysplasia, Crohn's)
- Anemia of chronic disease
- Specific stage . . .
March 17, 2015
Adverse effects and poisoning
Improving physician documentation specificity
- Is this an adverse effect (e.g., side effect or sensitivity to a drug correctly administered) or is this a poisoning (e.g., misuse of drug like an overdose, combination of a medication with alcohol)?
- Supply the name of the substance causing the complications (e.g., Prednisone, shellfish, Digoxin, latex)
- List all complications the . . .
March 17, 2015
Medication non-compliance
Improving physician documentation specificity
- Provide information regarding the intent (e.g., patient under-dosed themselves or failure to dose correctly during medical/surgical care).
- Document reason for non-compliance or underdosing, if known, (e.g., financial hardship or age-related dementia).
- Was the non-compliance or underdosing intentional or unintentional? Report any . . .
March 14, 2015
