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

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

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 96

Administration Outcomes Documentation/Coding Emergency Department 96

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

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 Seizures 94

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

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

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 Patient Safety 105

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 76

Documentation/Coding Administration Wellness 76

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

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

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

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

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

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 97

EMS Documentation/Coding Pediatrics Psychiatric 97

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

Mind The Bleep

APRIL 10, 2025

They can be fine tuned to respond to prompts and perform specific tasks such as finishing code, generating essays or textual responses to users. AI can book appointments and perform other administrative tasks, for instance, retrieving medical information and billing. One of the most famous LLMs is ChatGPT.

Documentation/Coding 52

Documentation/Coding Research Outcomes 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

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

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 114

EKG/ECG Documentation/Coding Emergency Department COPD 114

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

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

ACEP Now

OCTOBER 10, 2024

Between deployments, Dr. McCormick earned his Master of Business Administration from National University and medical degree from Morehouse School of Medicine in Atlanta. Right now, there’s no incentive to get people out of the emergency department by hospital administrators. OTHER EMERGENCY PHYSICIAN CANDIDATES Click to enlarge.

Telemedicine 105

Telemedicine Critical Access Hospitals Emergency Department 105

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

The Skeptics' Guide to EM

FEBRUARY 23, 2019

One recommendation that they make is the rapid administration of 30ml/kg of crystalloid for hypotension. Clinical Question: Is IV fluid administration by Paramedics for patients with suspected sepsis associated with reduced in hospital mortality rates? This is a strong recommendation from SSC based on low quality evidence.

Sepsis 52

Sepsis Administration Documentation/Coding Hospitals 52

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

American Medical Compliance

APRIL 29, 2024

This course will equip caregivers and administrative staff with the necessary tools and knowledge to identify, prevent, and address these grievous issues effectively. A Framework Against Abuse and Neglect in Nursing Homes Federal Code has established regulations to safeguard nursing home residents from abuse and neglect.

Elder Abuse 52

Elder Abuse Documentation/Coding Administration Outcomes 52