Documentation Guides
Complete documentation guides for 100+ medical conditions. Learn ICD-10 coding, HCC capture, and how Scribeable optimizes clinical documentation.
Heart and blood vessel conditions
Elevated blood pressure requiring ongoing management and monitoring.
Atherosclerotic heart disease affecting the coronary arteries.
Irregular heart rhythm originating in the atria.
Reduced ability of the heart to pump blood effectively.
Formation of a blood clot in a deep vein, most commonly in the lower extremities, with risk of pulmonary embolism.
Narrowing of peripheral arteries reducing blood flow to extremities.
Blood clot lodged in the pulmonary arteries causing acute obstruction of blood flow.
Dysfunction of one or more heart valves affecting blood flow through cardiac chambers.
Transient loss of consciousness due to cerebral hypoperfusion with spontaneous recovery.
Severe cardiac pump failure resulting in inadequate tissue perfusion and end-organ dysfunction.
Lung and airway conditions
Chronic inflammatory lung disease causing obstructed airflow.
Chronic airway inflammation causing reversible airflow obstruction.
Acute diffuse inflammatory lung injury causing severe hypoxemic respiratory failure.
Group of disorders causing progressive scarring and inflammation of lung interstitium.
Abnormal fluid accumulation in the pleural space between the lung and chest wall.
Repeated upper airway collapse during sleep causing intermittent hypoxia and sleep fragmentation.
Infection of the lung parenchyma causing inflammation and consolidation.
Elevated pressure in the pulmonary arterial system leading to right heart failure.
Hormone and metabolic conditions
Metabolic disorder characterized by insulin resistance and elevated blood glucose.
Underactive thyroid gland resulting in decreased thyroid hormone production.
Excess body weight as defined by BMI ≥30.
Chronic wound of the foot complicating diabetes mellitus, a leading cause of non-traumatic amputation.
Autoimmune destruction of pancreatic beta cells causing absolute insulin deficiency.
Acute metabolic emergency with hyperglycemia, ketosis, and metabolic acidosis.
Endocrine disorder characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology.
Inadequate cortisol production from the adrenal glands, either primary (Addison disease) or secondary.
Digestive system conditions
Chronic acid reflux causing esophageal symptoms.
Erosion of the gastrointestinal mucosa, typically in the stomach or duodenum, caused by acid and pepsin.
Chronic functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits without structural pathology.
Chronic liver scarring resulting in hepatic dysfunction and portal hypertension.
Hepatic steatosis associated with metabolic risk factors in the absence of significant alcohol use.
Chronic inflammatory bowel disease affecting any part of the GI tract with transmural inflammation.
Chronic inflammatory bowel disease causing continuous mucosal inflammation of the colon.
Autoimmune enteropathy triggered by gluten ingestion causing villous atrophy and malabsorption.
Acute inflammatory process of the pancreas with variable involvement of regional tissues.
Hemorrhage from any portion of the gastrointestinal tract, classified as upper or lower.
Bone, joint, and muscle conditions
Pain in the lumbar region with various potential etiologies.
Degenerative joint disease causing pain and stiffness.
Chronic autoimmune inflammatory disorder primarily affecting the joints with symmetric polyarthritis.
Inflammatory arthritis caused by deposition of monosodium urate crystals in joints and soft tissues.
Chronic autoimmune disease causing widespread inflammation across multiple organ systems.
Chronic inflammatory arthritis primarily affecting the sacroiliac joints and axial skeleton.
Inflammatory arthritis associated with psoriasis, affecting joints, entheses, and skin.
Chronic widespread musculoskeletal pain syndrome with tenderness and associated fatigue, sleep, and cognitive disturbance.
Brain and nervous system conditions
Recurrent headache disorder often with associated symptoms.
Sudden interruption of blood supply to the brain caused by arterial occlusion, resulting in neurological deficits.
Chronic neurological disorder characterized by recurrent unprovoked seizures.
Progressive neurodegenerative disorder affecting movement with dopaminergic neuron loss.
Autoimmune demyelinating disease of the central nervous system.
Mild traumatic brain injury from impact or rapid acceleration/deceleration forces.
Brief episode of neurological dysfunction from focal cerebral ischemia without infarction.
Damage to peripheral nerves causing sensory, motor, or autonomic dysfunction.
Progressive neurodegenerative dementia characterized by memory loss and cognitive decline.
Autoimmune neuromuscular disorder causing fluctuating muscle weakness from acetylcholine receptor antibody attack.
Mental health conditions
Persistent depressive mood and loss of interest affecting daily functioning.
Persistent excessive worry causing significant distress.
Mood disorder characterized by episodes of mania or hypomania alternating with depressive episodes.
Trauma-related disorder characterized by intrusive memories, avoidance, negative cognitions, and hyperarousal following exposure to a traumatic event.
Chronic psychotic disorder with hallucinations, delusions, disorganized thinking, and negative symptoms.
Anxiety disorder characterized by intrusive obsessions and repetitive compulsions.
Neurodevelopmental disorder with persistent inattention, hyperactivity, and impulsivity.
Problematic pattern of alcohol use causing significant impairment or distress.
Problematic pattern of opioid use causing significant impairment or distress, often requiring medication-assisted treatment.
Infections and communicable diseases
Life-threatening organ dysfunction caused by a dysregulated host response to infection.
Viral infection of the liver caused by the hepatitis C virus, often progressing to chronic disease.
Retroviral infection affecting the immune system, managed with antiretroviral therapy.
Toxin-mediated colitis caused by Clostridioides difficile, typically following antibiotic exposure.
Acute bacterial infection of the skin and subcutaneous tissues causing spreading erythema and inflammation.
Acute bacterial infection of the meninges causing inflammation of the brain and spinal cord coverings.
Tick-borne infection caused by Borrelia burgdorferi with multisystem manifestations across early and late stages.
Skin conditions
Chronic inflammatory skin condition characterized by pruritic, erythematous, and often lichenified lesions.
Chronic immune-mediated skin disease characterized by well-demarcated erythematous plaques with silvery scale.
Common inflammatory skin condition affecting pilosebaceous units, causing comedones, papules, and pustules.
Pruritic wheals and angioedema caused by mast cell degranulation, classified as acute or chronic.
Malignant neoplasms of the skin including basal cell, squamous cell, and in-situ carcinomas.
Kidney, bladder, and reproductive conditions
Bacterial infection of the urinary system, most commonly affecting the bladder and urethra.
Non-malignant enlargement of the prostate gland causing lower urinary tract symptoms in men.
Progressive loss of kidney function over months to years, classified by GFR stage and albuminuria category.
Sudden decline in kidney function with elevated creatinine or decreased urine output.
Blood and lymphatic conditions
Cancer and tumors
Malignant neoplasm of the breast, the most common cancer in women worldwide.
Malignant neoplasm of the bronchus or lung, a leading cause of cancer mortality.
Malignant neoplasm of the prostate gland, the most common cancer in men.
Malignant neoplasm of the colon or rectum, one of the most common cancers worldwide.
Malignant neoplasm arising from melanocytes, the most aggressive form of skin cancer.
Conditions primarily affecting children
Chronic airway inflammation in children causing recurrent wheezing and airflow obstruction.
Routine preventive health visit for pediatric patients including developmental screening and immunizations.
Infection or inflammation of the middle ear, one of the most common pediatric conditions.
Acute viral lower respiratory infection in infants and young children causing small airway inflammation.
Seizures occurring in young children associated with fever, without evidence of intracranial infection or other cause.
Long-term condition management
Pregnancy and childbirth conditions
Routine supervision and monitoring of normal pregnancy including scheduled prenatal visits and screenings.
Pregnancy-specific hypertensive disorder characterized by new-onset hypertension and proteinuria or end-organ dysfunction after 20 weeks gestation.
Glucose intolerance first recognized during pregnancy, affecting maternal and fetal outcomes.
Major depressive episode occurring during pregnancy or within the first year postpartum.
Chronic condition where endometrial-like tissue grows outside the uterus causing pain and infertility.
Eye and vision conditions
Microvascular complication of diabetes causing progressive damage to the retinal blood vessels with potential vision loss.
Progressive optic neuropathy characterized by optic nerve damage and visual field loss, often associated with elevated intraocular pressure.
Progressive degeneration of the macula causing central vision loss in older adults.
Allergy and immune system conditions
Complete documentation guides for medical conditions. Learn ICD-10 coding, documentation requirements, and billing considerations.