Clinical Documentation Tip Sheets

Neuroscience

This tip sheet is designed to assist physicians in accurately assessing and documenting the severity of illness in hospitalized patients within the electronic medical record (EMR).

FUNCTIONAL QUADRIPLEGIA

TIA

CVA/ STROKE

> Document: Neurologic deficits, e.g.. hemiparesis, quadriparesis, aphasia, dysphagia, neurologic neglect , etc. Tip: If CT/MRI shows “midline shift” or “mass effect” consider documenting brain compression . If CT/MRI shows “cerebral edema” or “brain herniation” consider adding those to your no

> Definition: Functional quadriplegia is used to describe patients who are completely immobile for reasons other than an injury to the spinal cord. Per CMS, these patients are completely bedbound and dependent on others for all ADLs (feeding, grooming, turning, bathing, etc.) Tip: Complete immobility codes to functional quadriplegia

> Document : a more specific diagnosis such as: carotid artery stenosis, vertebro-basilar artery syndrome, cerebral ischemia, amaurosis fugax, transient global amnesia, etc. > Avoid: cerebral insufficiency , document cerebral infarction instead

ENCEPHALOPATHY

DELIRIUM

COMA

> Type: metabolic, septic, toxic, hepatic, uremic, hypertensive, etc. Tip: Document if the encephalopathy (altered mental status) is same as baseline, more than baseline, worsened or improved

> Definition: GCS score is below 9

> Acuity: acute, chronic

> Document: the individual eye, verbal, and motor scores

> Cause: Due to medical condition, superimposed on dementia, due to alcohol, drugs, ICU delirium, mixed etiology, etc

DEMENTIA

SEIZURES

CEREBRAL PALSY

> Type: Alzheimer’s, Vascular, Lewy body, etc. > With or without behavioral disturbance: e.g., anxiety, depression, behavioral, mood or psychotic disturbance. Tip: document delirium and/or encephalopathy superimposed on dementia when present.

>Type: Focal, generalized

>Type: spastic, dyskinetic, ataxic, hypotonic, and mixed > Associated Paralysis: diplegia, hemiplegia, quadriplegia > With or without intellectual disability

Intractable or not interactable With or without status epilepticus