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

Emergency Medicine Journal

AUGUST 23, 2023

Interviews were transcribed verbatim and coded inductively by the primary researcher. We coded all items to capture experiences of 111 First within the full project coding tree and from this constructed two explanatory themes which were refined by the wider research team.

Emergency Department 75

Emergency Department Urgent Care Documentation/Coding Patient Safety 75

American Medical Compliance

APRIL 1, 2024

What you will learn Principles, code of professional conduct, and advisory opinions Patient Autonomy Nonmalfience Benefience Indiana Statuses and Administrative Rules Licensure of Dentists Licensure of Dental Hygienists Details Course length: 2 hours. These are the ADA Principles of Ethics and Code of Professional Conduct (ADA Code).

Documentation/Coding 59

Documentation/Coding Administration Wellness 59

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

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

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 118

Sepsis Fluid Resuscitation Resuscitation Administration 118

ACEP Now

OCTOBER 26, 2023

One of the HCFA letters, written by then Medicaid Director Tim Westmoreland (the Westmoreland Letter) specifically cited that the CPT 9928X codes should be reimbursed under federal PLP unless the Medicaid plan believed there were program integrity issues with the claim.

Documentation/Coding 124

Documentation/Coding Hospitals Emergency Department Administration 124

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

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 91

Administration Outcomes Documentation/Coding Emergency Department 91

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 95

Stroke Administration Documentation/Coding Outcomes 95

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

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

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 Infectious Diseases 105

EMDocs

OCTOBER 10, 2024

Exam is normal except for tenderness as documented in the diagram. She never had a documented abdominal exam. I just failed to document it. The EP documented seeing the patient and agreed with the ARNP’s plan. Delay in administration of antibiotics. Temp is 98.7 and pulse 121. My pain increased when walking.

Documentation/Coding 93

Documentation/Coding Hospitals Sepsis Infectious Diseases 93

Sensible Medicine

AUGUST 21, 2023

Administrative data sets are often collected for the purpose of billing, or costing, or administrative organization, and thus are extremely vulnerable to up coding or intentional or accidental omissions. This means that the data on which the observations are based, independently of how they are analyzed, are not reliable.

Administration 98

Administration Outcomes Research COPD 98

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 74

Documentation/Coding Administration Wellness 74

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

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

Taming the SRU

MAY 11, 2024

3% HTS appears to be safe for peripheral IV administration and does not require a central line. The available data does not support any benefit of administration of hyperosmolar therapy in the setting of a TBI. When administered IM, midazolam administration appears superior in terms of time to sedation (Nobay et al.).

Administration 92

Administration Resuscitation Fluid Resuscitation Research 92

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

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

American Medical Compliance

MARCH 14, 2025

What You Will Learn: What constitutes a covered entity under HB 300 Patients’ right to access, amend, and restrict the use of their health information under Texas law Administrative, physical, and technical safeguards required to secure PHI Details: Course length: 30 minutes; CME: 0.5

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52

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

APRIL 29, 2024

Hospital administrators put VAP on the kill list. And maybe, noticing all the fuss, some clinicians might have started coding for VAP slightly less often in equivocal cases. In 2008, the U.S. government proposed adding VAP to its “hospital-acquired conditions” list—the ones that it won’t pay for.

Documentation/Coding 52

Documentation/Coding Academics Administration Research 52

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 101

Outcomes Academics Documentation/Coding Emergency Department 101

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 95

EMS Documentation/Coding Pediatrics Psychiatric 95

Mind The Bleep

OCTOBER 22, 2024

Behind the scenes, this entry is assigned a clinical code (such as a SNOMED CT code) so it can be recognised as a blood pressure value by any health record software worldwide if the record should ever be exported there. Some clinicians might have an interest in coding and software development (also known as clinicians who code ).

Documentation/Coding 59

Documentation/Coding Telemedicine Urgent Care Operations 59

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 EMS 98

Downeast Emergency Medicine

DECEMBER 1, 2021

The investigators used thematic analysis to independently code transcripts using an initial set of deductive codes, followed by inductive codes developed during the coding process. All transcripts were then coded using a final code book and resultant codes were organized into themes and subthemes with supportive quotes.

Emergency Department 52

Emergency Department Documentation/Coding Leadership Administration 52

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

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

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 117

EKG/ECG Documentation/Coding Emergency Department COPD 117

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

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

American Medical Compliance

JUNE 5, 2024

The DEA Information for Dental Healthcare Practitioners Training educates dental healthcare practitioners (DHCP) on the Drug Enforcement Administration (DEA) policies for controlled substances. Conversely, the DEA updates the schedules annually and publishes them in Title 21 of the Code of Federal Regulations, Sections 1308.11

Administration 52

Administration Documentation/Coding Research 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

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 133

Stroke Outcomes Hospitals Administration 133