Sensible Medicine

AUGUST 2, 2024

I often say to patients (as I apologize for documenting while I get to know them) that I had sworn as a medical student never to be the doctor that types during visits—and when I first became an attending, I held to that. Ideally, I would have a schedule where I could document in the time after a patient leaves the visit.

Documentation/Coding 75

Documentation/Coding Administration Wellness 75

PEMBlog

MARCH 4, 2025

Studies supporting antibiotic treatment of documented mycoplasma pneumoniae in children are limited. We also don’t know whether administration of antibiotics decreases the incidence or severity of associated mucocutaneous disease. There was publication bias, heterogeneity, and lack of blinding. I can’t bear it.

Pediatrics 94

Pediatrics Military CDC Hospitals 94

American Medical Compliance

AUGUST 7, 2024

OSHA (Occupational Safety and Health Administration) Adhering to OSHA (Occupational Safety and Health Administration) regulations is vital for ensuring safe and healthy working conditions for healthcare workers. For example, CMS requires accurate and timely documentation of patient care to ensure proper billing and reimbursement.

Hazardous Materials 105

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 105

The Trauma Pro

JULY 19, 2024

This keeps your documentation clean and easier to follow. As for timing, there are two choices: always make each meeting a fixed length, or limit your first meeting to an exact length and allow the second to start at a fixed time and have a variable duration. Finally, make sure the contents and minutes of the two meetings are separate.

Operations 113

Operations Documentation/Coding Administration 113

American Medical Compliance

OCTOBER 3, 2024

Occupational Safety and Health Administration (OSHA) regulations are vital for maintaining a safe and healthy work environment in all industries. This can be achieved by maintaining a centralized document repository. Have a digital document management system or a physical binder in a prominent area of the dental office.

PPE 105

PPE Hazardous Materials Documentation/Coding Operations 105

ACEP Now

DECEMBER 6, 2024

Repeat ECG following return of spontaneous circulation after administration of intravenous nitroglycerin. The decision was made to communicate directly with the on-call interventional cardiologist with specific and direct intent to discuss the administration of intravenous (IV) NTG. Click to enlarge.) What Would You Do Next?

Resuscitation 98

Resuscitation EKG/ECG Documentation/Coding COPD 98

EMDocs

JUNE 8, 2023

and 9 hours after onset of symptoms, with non-infarcted brain tissue, does the administration of alteplase improve functional outcome at 90 days? Subsequently reduced enrollment to 310 patients because no patients had been lost to follow-up or had insufficient data documented. Intervention: Alteplase 0.9 in alteplase group versus 0.9%

Stroke 98

Stroke Administration Documentation/Coding Outcomes 98

RebelEM

JULY 3, 2023

Pregnant or incarcerated patients Documentation for systolic BP is incomplete Intervention: Administration of IV calcium within 60 min prior to or 30 min after IV diltiazem administration in patients with AF/AFL with RVR. The study was dependent on EMR documentation which is prone to error. received CaCl 89.3%

Administration 98

Administration Outcomes Documentation/Coding Emergency Department 98

RebelEM

JUNE 8, 2023

The retrospective design of this study omitted assessment of ventricular dysrhythmias related to push dose pressor administration, as they were reliant on information in the EMR. Assessed clinical practice, outcome, length of stay, safety, and efficacy of both phenylephrine and epinephrine peripherally administered through a push dose.

Administration 98

Administration Emergency Department Outcomes Documentation/Coding 98

EMDocs

JUNE 9, 2023

We’re defining “protocol” here as a written document that provides oversight from the medical director about how to assess and treat patients. These protocols are often developed in collaboration with multiple stakeholders that can include EMS staff and administration, legal counsel, community members, law enforcement.

EMS 98

EMS Documentation/Coding Pediatrics Psychiatric 98

The Trauma Pro

OCTOBER 31, 2023

Contact the trauma medical director, service chief, or hospital administrator and see if they can intervene. Explain to the consultant that you truly believe that harm will occur, and you will have to document that fact in the medical record as well as their failure to respond. Appeal to a higher authority.

Risk Management 113

Risk Management Fractures Documentation/Coding Hospitals 113

American Medical Compliance

FEBRUARY 17, 2024

With the Occupational Safety and Health Administration (OSHA) setting standards to protect workers from occupational hazards, healthcare organizations face unique challenges in maintaining compliance due to the complexity of their operations and the diverse array of risks inherent in patient care.

Best Practices 105

Best Practices PPE Infectious Diseases Documentation/Coding 105

RebelEM

NOVEMBER 30, 2023

For those with sepsis, the administration of intravenous fluids (IVF) at the volumes recommended in the Surviving Sepsis Campaign (SSC) requires careful consideration of an individual’s chronic medical conditions and subsequent sensitivity to IVF. Studies without a clear timeframe for fluid administration. 2.89, p = 0.01.

Sepsis 121

Sepsis Fluid Resuscitation Resuscitation Administration 121

ACEP Now

OCTOBER 3, 2023

This document is an update of guidelines first published in 2000, and then updated in 2007. Confounders to the GCS such as seizure and post-ictal phase, ingestions and drug overdose, as well as medications administered in the prehospital setting that impact GCS score should be documented. References Lulla A, et al. 2019;154(7):e191152.

Fluid Resuscitation 98

Fluid Resuscitation Documentation/Coding Resuscitation Pediatrics 98

Advanced Medical Reviews

FEBRUARY 13, 2019

It is intended to streamline workflow, reduce administrative burden and improve patient care, but when poorly designed, technology may increase stress for physicians. Physicians who reported marginal time for documentation were 2.8 Clinical information and documentation are all streamlined through our web interface.

Documentation/Coding 64

Documentation/Coding Administration Operations Research 64

PulmCCM

JANUARY 6, 2025

With financial penalties coming for noncompliance with the new rule, hospital administrators rapidly deployed the alerts to fire on all eligible inpatients. This was despite a higher intensity of care in the visible-alert patients, who had more rapid responses, ICU transfers, code blues, intubations, and initiation of dialysis.

Sepsis 45

Sepsis Documentation/Coding Hospitals Outcomes 45

RebelEM

AUGUST 22, 2024

Administration of intravenous tissue plasminogen activator (IV tPA) within 4.5 Administration of intravenous tissue plasminogen activator (IV tPA) within 4.5 Moreover, there are multiple operational and patient-specific barriers rendering timely thrombolytic administration difficult. Timely recognition of RAO is challenging.

Stroke 85

Stroke Administration Outcomes Documentation/Coding 85

EMDocs

SEPTEMBER 30, 2024

Among patients with a primary provider documented in the chart, 30-day outpatient follow-up rate was 21.3% (n = 313). The primary comparison was between administration of ICS in addition to systemic corticosteroids (SCS) and to SCS alone. Design: Included RCTs from PubMed, The Cochrane Library, and EMBASE.

Outcomes 105

Outcomes Academics Documentation/Coding Emergency Department 105

ACEP Now

DECEMBER 11, 2023

A recent article documents 56 additional U.S. The wave of increasing hospital closures and service line cutbacks continues to sweep the U.S. hospitals that are closing clinical departments or ending or reducing services. 2 Of these 56 additional hospitals, many are not rural; thus, this specter is expanding. physicians quit in 2021 alone.

Hospitals 98

Hospitals Administration Documentation/Coding Research 98

PulmCCM

FEBRUARY 5, 2024

You can read the document here. Read the original document here. to enforce compliance with an administrative policy). Please comment below if you have any suggested additions or edits to this document. Virtually all the recommendations were based on weak evidence and represent a consensus of expert opinion.

Best Practices 111

Best Practices Ultrasounds Infectious Diseases Sepsis 111

Dr. Smith's ECG Blog

OCTOBER 12, 2024

The providers documented concern for ST elevation in the precordial and lateral leads as well as a concern for hyperkalemic T waves in the setting of succinylcholine administration. Preliminary findings documented in the cath lab were “Anterior STEMI and no significant coronary artery disease.” (!!!) Potassium resulted as 4.9,

EKG/ECG 116

EKG/ECG Documentation/Coding Emergency Department COPD 116

PEMBlog

JUNE 14, 2023

Marianne Gausche-Hill New England EMSC: New England Regional Behavioral Health Toolkit Disclaimer The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Pediatrics March 2023; 151 (3): e2022057383. 10.1542/peds.2022-057383 2019.6.42422.

Psychiatric 98

Psychiatric Emergency Department Pediatrics Best Practices 98

Total Medical ComplianceHIPAA

JANUARY 12, 2023

During those two years, the OCR oversees all compliance activities and requires that all HIPAA related documentation and issues be submitted and approved or reported to them according to strict guidelines. The penalty for not following the corrective action plan could result in a Civil Monetary Penalty.

Operations 104

Operations Best Practices Documentation/Coding Administration 104

RebelEM

JANUARY 29, 2024

PMID: 37188358 Clinical Question: What is the efficacy and safety of low-dose (25mg) prolonged administration (over 6hrs) of alteplase in patients with massive PE? Reduced-Dose Systemic Fibrinolysis in Massive Pulmonary Embolism: A Pilot Study. Clin Exp Emerg Med 2023.

Stroke 136

Stroke Outcomes Hospitals Administration 136

Northwestern EM Blog

OCTOBER 31, 2022

In addition, it is imperative that hospitals and emergency departments establish clear processes and appropriate documentation for EMTALA-related situations. The infographic by Dr. Tandlich gives an excellent summary of EMTALA.

Emergency Department 52

Emergency Department Administration Documentation/Coding Hospitals 52

Total Medical ComplianceHIPAA

OCTOBER 15, 2022

If a patient emails a request for their records, it is considered sufficient documentation for the practice to provide those records once the practice confirms the email address belongs to the patient. For example, if the patient’s email is not on file, call to confirm the request and email address and document the call in the patient’s file.

Documentation/Coding 52

Documentation/Coding Administration Wellness 52

Greater Sydney Area HEMS

AUGUST 1, 2023

When I found it, I felt the documentation (if done at all) largely tended to be the bare minimum, and certainly not reflective of the beautiful learning conversations happening in the room. We knew this would involve improving C+C learning summary documentation standards, and effectively disseminating content across the organisation.

Documentation/Coding 52

Documentation/Coding Outcomes Hospitals Administration 52

ACEP Now

JUNE 7, 2023

Another proposed application for LLMs involves transcription and summarization services to reduce administrative overhead. The example provided illustrates both the potential and current limitations of the technology, presently requiring careful review to ensure spurious extrapolations have not been inserted into the medical documentation.

Documentation/Coding 78

Documentation/Coding Wellness Administration Research 78

Ziqitza HealthCare Ltd

JUNE 18, 2023

Streamlining Administrative Tasks: Improving Efficiency and Reducing Costs AI can automate administrative tasks, such as appointment scheduling, billing, and medical coding, freeing up healthcare professionals’ time and reducing administrative burdens.

Documentation/Coding 52

Documentation/Coding Administration Ambulance Services Outcomes 52

ACEP Now

JUNE 1, 2023

Documentation LLMs can assist with generating initial drafts of referral letters, medical excuses, and discharge summaries. Generated content should always be reviewed and edited to ensure accuracy and compliance with medical documentation standards. They can help draft research papers or grant proposals.

Best Practices 52

Best Practices Research Documentation/Coding Emergency Department 52

Emergency Medicine Journal

NOVEMBER 28, 2023

Data was routinely collected from Comprehensive Geriatric Assessments, and entered prospectively onto Excel by a trained administrator. Age, Gender, Clinical Frailty Score (CFS) and documentation of ‘WMTY’ was analysed. 468 (79%) patients had documentation of WMTY. Results 592 patient responses were analysed.

Emergency Department 40

Emergency Department Documentation/Coding Administration Hospitals 40

Taming the SRU

JUNE 3, 2024

glenn, haffner, and jackson In Flight Emergencies: As a responding physician to an in-flight emergency, you may recommend diverting the plane, however, the captain (lead pilot) will make the final decision.

Shock 91

Shock Seizures Airway Management Stroke 91

ACEP Now

JUNE 7, 2023

ED leaders worked to develop new physician documentation and coding guidelines that needed to be implemented at the beginning of 2023. These data can be shared with hospital administration as there is mutual need to find solutions to the current ED flow challenges and very high ED walkaway rates.

Emergency Department 52

Emergency Department Documentation/Coding Operations EMS 52

EMDocs

JUNE 2, 2023

Route of administration If the patient is cooperative, offer oral medications first. Document what you gave and why, as well as the impact. You should always follow your local practice guidelines and recommendations as well as adhere to approved medications in your facility. If a patient has a PRN on their med list do that!

Psychiatric 93

Psychiatric Pediatrics Emergency Department Administration 93

American Medical Compliance

FEBRUARY 15, 2023

Every year, organizations that provide prescription drugs, health care, or administrative services to persons who have Medicare Advantage (MA) or Prescription Drug Plan (PDP) instead of a health plan must complete this training. Documentation of this distribution is required. This affects everyone, including you.

Administration 52

Administration Documentation/Coding Operations 52

American Medical Compliance

FEBRUARY 15, 2023

Every year, organizations that provide prescription drugs, health care, or administrative services to persons who have Medicare Advantage (MA) or Prescription Drug Plan (PDP) instead of a health plan must complete this training. Documentation of this distribution is required. This affects everyone, including you.

EMS 52

EMS Administration Documentation/Coding Operations 52

Don't Forget the Bubbles

DECEMBER 16, 2024

Depending on the individuals circumstances, this may involve either the administration of the MMR vaccine within 72 hours of exposure or intravenous immunoglobulin within six days. JOINT committee on vaccination and immunisation code of practice June. European Centre for Disease Prevention and Control. Measles facts [Internet].

Infectious Diseases 59

Infectious Diseases Documentation/Coding Pediatrics CDC 59