Alzheimer s Disease Attention Disder Document onset as: -Early -Late Document site, such as: - Predominantly inattentive - Predominantly hyperactive - Combined type If with dementia, document as: -With behavial disturbance, f example combative and/ aggressive behavi -Without behavial disturbance Cerebral Infarction & Occlusion Document etiology: - Due to embolus, thrombosis, occlusion, stenosis -Right -Left Document specific artery affected: - Precerebral (vertebral, basilar, carotid) - Cerebral artery (middle, anteri, posteri) - Cerebellar arteries Specify if intraoperative postprocedural complication Document any related deficits: (Right left hemiparesis, aphasia, seizure, etc.) Cognitive Signs & Symptoms Identify when signs and symptoms are related to a known mental disder List any associated: - Current injuries - Late effects of past events. -TPA administration Clarify type of mental disturbances: - Altered mental status - Age-related cognitive decline - Confusion - Dementia Diabetic Neuropathy Dominant Nondominant Side Drug Underdosing Epilepsy Rather than diabetic neuropathy, if known suspected document instead: -Diabetic mononeuropathy -Diabetic polyneuropathy -Diabetic autonomic neuropathy -Diabetic amyotrophy -Other neurological complication Document side affected as: -Dominant -Nondominant - Intentional versus - Unintentional -Intractable versus not intractable And -With without status epilepticus If control is not maintained of blood glucose levels, document insulin control status as: - Inadequately controlled - Out of controlled - Poly controlled -Monoplegia -Hemiplegia -Other paralytic syndromes Document reason f underdosing, such as: -Financial hardship - Age related dementia Specify type: -Localization-related idiopathic symptomatic -Simple partial complex partial seizures -Generalized idiopathic If specify side is not documented as dominant nondominant: -Right side defaults to dominant -Left side defaults to nondominant Identify any special epileptic syndromes: -Seizures related to alcohol, drugs, sleep deprivation, etc. Include descriptions of poly controlled pharmacesistant, treatment resistant and refracty Version 1.0 Page 1
Gait Disturbance Headache Maj Depressive Disder Memy Loss Migraine Malnutrition Myalgia Pathological Vertebral Fractures Pressure Ulcers Pulmonary Embolism - Ataxic - Paralytic - Spastic - Staggering - Cluster - Vascular - Tension-type - Post-traumatic - Drug-induced (specify drug) Document episode: - Single - Recurrent - Disientated Anterograde Amnesia - Retrograde Amnesia - Age related - Altered mental status - Migraine w/ aura - Migraine w/o aura - Hemiplegic migraine - Persistent migraine aura w/o cerebral infarction - Persistent migraine aura w/ cerebral infarction migraine -Protein calie -Protein energy Document specific location: - Shoulder - Upper arm - Fearm - Hand - Fingers - Thigh - Ankle Specify whether etiology is: - Age related - Disuse osteopenia - Neoplastic - Some other disease Must document diagnosis of pressure ulcer Document type, such as: - Saddle - Septic - Falling - Unsteadiness - Difficult walking Document severity: - Mild - Moderate - Severe w/o psychotic symptoms - Severe w/ psychotic symptoms Identify when migraine is due to drugs and specify the drug - With status migrainosus - Without status migrainosus Document severity: -Mild 1 st degree -Moderate 2 nd degree -Severe 3 rd degree Detail when paralysis burns accompany the calcification and ossification of muscles. Document any underlying disease - Right - Left - Bilateral Document site and stage Document c pulmonale if present and whether it is: - Acute Document timing: - Episodic - Episodic paroxysmal hemicrania paroxysmal hemicrania - Sht lasting unilateral Indicate status: - Full remission - Partial remission Identify when migraine is associated with seizures cerebral infarction Document BMI Document any rupture: - Non-traumatic ischemic - Infarction - Wasting - Contracture of a muscle Note: Stage of pressure ulcer can be taken from nursing notes Specify if: -Chronic (still present) Versus -Healed/old -Note that histy of PE is ambiguous Version 1.0 Page 2
Respiraty Failure Seizures Sequelae of Cerebrovascular Disease Skin Disturbance Spinal Column Site Transient Ischemic Attack (TIA) - Acute - Acute on chronic Seizures not diagnosed as a disder recurrent (i.e., nonepileptic) should specify the condition as being: - Febrile specify simple complex - New onset - Single seizure convulsion - Post traumatic hysterical - Autonomic Cause & Effect, use due to Secondary to to link cause and effect. When present, document sequelae: - Congnitive - Monoplegia - Speech: - Hemiplegia - Aphasia - Dysphasia - Dysarthria - Fluency disder -Right -Left -Bilateral Detail any associated condition disease (e.g., easy bruising, leukemia) Document site, affected as: - Occipito-atlanto-axial - Cervical cervical-thacic - Thacic thacolumbar - Lumbar lumbosacral - Sacral sacrococcygeal Document, if known suspected, rather than TIA: - Vertebro-basilar artery syndrome - Carotid artery syndrome - Precerebral artery syndrome - Amaurosis fugax - Transient global amnesia cerebral ischemic attacks and Syndromes Document, if acute respiraty failure: - Hypoxemic - Hypercapnic -Both Describe seizures as: - Localized onset - Simple partial - Complex partial List specific sensy disturbances such as: - Hypoesthesia - Paresthesia - Hyperesthesia Document site f spinal cd injury: - Cervical = identify each vertebral segment - Thacic = identify as T1, T2-T6, T7-T10, T11-12 - Lumbar = identify each vertebral segment - Sacral = no additional specificity needed Note: of TIA = unspecified code Further describe seizures as: - With status epilepticus - Without status epilepticus Identify the underlying cause of any sign and symptom when known. Version 1.0 Page 3
Traumatic Brian Hemrhage Traumatic Vertebral Fractures Trems Procedures Arterial Catheterization Arteriogram Central Venous Catheter Placement Excision of Intervertebral Disc Injection/Infusion Specify site: - Left right cerebrum - Cerebellum - Brainstem - Epidural - Subdural - Subarachnoid -Level of vertebral, example L1 - Displaced versus nondisplaced - Part of vertebra fractured, example posteri arch -Abnmal head movements -Trem -Cramp/spasm -Fasciculations (twitching) Document site of artery: - Abdominal ata - Anteri tibial - External iliac - Renal - Common carotid - Hand - etc. Document if done with: - Plain radiography - Fluoscopy Document site: - Artium - Inferi vena cava - Innominate vein - Subclavian vein - Superi vena cava Differentiate: - between removal of a ption - All of an intervertebral disc - Substance administered (analgesic, anti- infective, sedative, anti-inflammaty, etc.) Specify if with LOC and f how long - Type ll dens fracture of the 2 nd cervical vertebra - Type lll spondylolisthesis of the 2 nd cervical vertebra - Stable versus unstable burst fracture - Zone l-lll Type 1-4 sacral fracture - Right - Left - Bilateral Document site: - Abdominal ata - Hepatic artery - Lumbar arteries - Lower arteries Document substance administered: -No substance -Antibiotics Antineoplastic -Dialysis -Nutritional substance -other substance Injection/infusion of thrombolytic agent - Document Substance: - Recumbinant Human-activated Protein C Thrombolytic endoscopic Document type of contrast used: - None - Low osmolar - High osmolar endoscopic Version 1.0 Page 4
Insertion Vascular Stent Transfusion Spinal Fusion Document specific site: - Olfacty - Optic - Facial - Vagus - Femal - Sciatic - Sacral - Etc. - Substance transfused: (FFP, RBC, albumin, etc.) - Autologous nonautologous -Level of spinal involved and -Number of vertebral joints fused Document if the approach: endoscopic Document when blood was collected: - Pri to surgery - Intraoperative/perioperative/ post-operative (24 HR period surrounding surgery) - Previously collected - Salvage (24 HR period surrounding surgery) Document, f operative approach: -Anteri approach, anteri -Posteri approach, posteri -Posteri approach, anteri Document site of administration: - Central artery vein - Peripheral artery vein Version 1.0 Page 5