The Trauma Pro

JULY 5, 2024

The emergency physician should be sure to convey their concerns very clearly, tell the specialist that the conversation will be documented carefully, and then do so. Be sure to fill out a consent as soon as practical, and document any attempts that were made to obtain it. Make sure all is documented well on the consent or in the EHR.

Documentation/Coding 113

Documentation/Coding Fractures Emergency Department Wellness 113

Resus Review

FEBRUARY 12, 2015

Part of performing a bedside percutaneous tracheostomy is the procedural documentation. Given that this is a surgical procedure, the documentation should be more thorough than you may be accustomed to doing for an arterial line or central line. I have included a sample procedure note below.

Documentation/Coding 40

Documentation/Coding 40

Emergency Medicine News

MARCH 31, 2024

An abstract is unavailable.

Documentation/Coding 40

Documentation/Coding 40

EB Medicine

SEPTEMBER 13, 2024

Eckler, MD discuss the September 2024 Emergency Medicine Practice article, Elder Abuse and Neglect: Making the Diagnosis and Devising a Treatment Plan in the Emergency Department Introduction and Announcements Elder Abuse and Neglect: An Overview Risk Factors and Reporting Pre-Hospital and Emergency Department Considerations Screening Tools and (..)

Elder Abuse 85

Elder Abuse Emergency Department Documentation/Coding Hospitals 85

The Trauma Pro

JUNE 21, 2024

This situation was first documented in a paper published in the 1960s, which noted that VIP patients have worse outcomes. The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. Who is a VIP? It may be a celebrity. A family member.

Documentation/Coding 288

Documentation/Coding Outcomes Hospitals Wellness 288

The Trauma Pro

AUGUST 15, 2023

MTP logistics include details such as who will be delivering the blood, what actually goes in each cooler, what ratios should be used, limitations imposed by the use of frozen plasma, and documentation. Documentation is critically important, both in the trauma bay and the blood bank. And there are plenty around all the time!

Documentation/Coding 130

Documentation/Coding Best Practices Resuscitation Administration 130

American Medical Compliance

MARCH 11, 2024

These are recordkeeping and documentation. In a survey , dental providers agree that careful and precise recordkeeping is indispensable, emphasizing the importance of documenting elements such as patient histories, examination results, diagnoses, radiographs, treatment plans, consent forms, and clinic notes.

Documentation/Coding 95

Documentation/Coding Best Practices Operations Outcomes 95

Total Medical ComplianceHIPAA

AUGUST 15, 2024

Document what worked well and what did not. Documentation and Compliance Comprehensive Documentation : Maintain detailed documentation of the DRP, including all tests, training sessions, and updates. This documentation is essential for demonstrating compliance with HIPAA requirements.

Documentation/Coding 59

Documentation/Coding Best Practices Risk Management Wellness 59

The Trauma Pro

NOVEMBER 10, 2023

You can download the full document using the link at the bottom of this post. Document your consultation results in writing (paper or EMR) promptly. Click here to download a sample Trauma Services consultant guidelines document. We have disseminated guidelines to our colleagues, and I wanted to touch on some of the main points.

Documentation/Coding 147

Documentation/Coding Best Practices 147

Clinical Correlations

NOVEMBER 1, 2024

By Chloe Fong Peer Reviewed The correlation between vitamin deficiency and alcohol use disorder (AUD) has been well documented in the literature, with a study from 1963 finding that 70% of patients admitted to the hospital.

Documentation/Coding 52

Documentation/Coding Hospitals Wellness 52

EMCrit

DECEMBER 10, 2023

Some authors on the ATS document were from Europe, and similarly some authors […] EMCrit Project by Josh Farkas. Within the past year, two major societies have released guidelines on ARDS: the ATS (American Thoracic Society) and the ESICM (European Society of Intensive Care Medicine).

Documentation/Coding 131

Documentation/Coding 131

EMDocs

JULY 25, 2024

The nurse completes the Columbia-Suicide Severity Rating Scale (C-SSRS) and documents that the patient’s recent thoughts of killing himself and his detailed plan makes him “High Risk” for suicide. There is no documented handoff to the on-coming emergency physician (EP) who assumes care. ” 0700 : The PA-C goes off-shift.

Documentation/Coding 81

Documentation/Coding Hospitals Patient Safety Emergency Department 81

American Medical Compliance

JUNE 21, 2024

Here are key areas where they can make a significant impact. Accurate Documentation and Coding Accurate documentation and coding are fundamental in preventing fraud, waste, and abuse. Providers must ensure that patient records accurately reflect the services provided and that coding accurately represents these services.

Documentation/Coding 99

Documentation/Coding Leadership Best Practices Outcomes 99

Science Based Medicine

AUGUST 14, 2024

These benefits are all well researched and copiously documented. We have often stated here on SBM that vaccine programs are the most effective, and most cost effective, public health measures in human history. They save lives, prevent disease, and save money.

CDC 76

CDC Documentation/Coding Research Wellness 76

Science Based Medicine

APRIL 21, 2024

New documents released yesterday confirm his prediction." - Dr. Jay Bhattacharya January 2024 The post Science Based Satire: BOMBSHELL NEWS!!! "Last year, @WashburneAlex made a bombshell prediction supporting the lab leak theory. The Virus I Told You Not to Worry About and Worked to Infect You With… CAME FROM A LAB!!!

Documentation/Coding 88

Documentation/Coding 88

Emergency Live

JANUARY 24, 2024

These confraternities, originating in Italy, have deep roots dating back to the Middle Ages, with the earliest historical documentation attesting to the foundation of the Misericordia of Florence […] The post The Misericordie: a history of service and solidarity appeared first on Emergency Live.

Documentation/Coding 98

Documentation/Coding 98

EM Ottawa

SEPTEMBER 28, 2023

You are treating a 43-year-old male with two days of left lower quadrant abdominal pain, a documented fever of 38.4 and malaise. He has no urinary or bowel symptoms. His past medical history is unremarkable. He looks well by ED standards. After a focused history and physical examination, you narrow the differential to diverticulitis.

Documentation/Coding 110

Documentation/Coding Wellness Infectious Diseases EMS 110

Emergency Live

JANUARY 20, 2024

One of the earliest documented female firefighters was Molly Williams, a member of Oceanus Fire Company No. The Pioneers in the Fight Against Fires in the Victorian Era The Early Flames of Change The history of women in firefighting has deep roots dating back to the early 1800s.

Documentation/Coding 98

Documentation/Coding 98

Science Based Medicine

OCTOBER 16, 2023

This is an old finding that needs to be documented periodically and shows why the acceptance of non-science-based treatments by physicians endangers vaccination efforts. A recent study reaffirms the high degree of correlation among physicians between antivax views and an embrace of quackery.

Documentation/Coding 101

Documentation/Coding 101

The Trauma Pro

OCTOBER 18, 2024

To take some of the variability out of the decision-making process for admitting service, two surgical groups on Long Island created a scoring system that incorporated several parameters described in the ACS Optimal Resource Document (Orange book).

Documentation/Coding 147

Documentation/Coding Emergency Department Hospitals 147

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 60

Documentation/Coding Administration Wellness 60

EMDocs

SEPTEMBER 26, 2024

An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. It wasn’t, so you weren’t called, nor did the doc need to document anything. This patient’s history was either poorly taken or poorly documented. Too much weight was given to the EKG, CXR, and labs.

Radiology 74

Radiology Radiology EKG/ECG Documentation/Coding 74

The Trauma Pro

MARCH 14, 2024

Related link: Facilities Guidelines Institute documents In this case, the FGI guidelines say nothing about the trauma team size, which is a critical factor in space planning. Use the work of others as a springboard to jump start your own efforts at solving the problem.

Resuscitation 162

Resuscitation Documentation/Coding Hospitals 162

The Trauma Pro

SEPTEMBER 10, 2024

And there are far more papers written than actual documented cases. For this reason, I’ll focus on field amputation for the rest of this issue. In reality, these procedures are discussed much more often than performed. There is one old paper that is cited frequently which consisted of a survey from 1996!

EMS 230

EMS Documentation/Coding 230

EMDocs

MAY 9, 2024

Exam documents that he is alert and oriented but “tired appearing” and “not appearing post-ictal.” Defense : The EP did address the seizure when he documented “not post-ictal.” There is no negligence, as the documentation supports reasonable judgment. The triage nurse records the event as a “seizure” lasting 7 minutes.

Seizures 82

Seizures Dehydration Documentation/Coding Infectious Diseases 82

EM Ottawa

OCTOBER 3, 2024

” However, when we combine POCUS images with clinical documentation, we are telling a story — and every good story has a beginning, middle, and end. Point-of-care ultrasound (POCUS) is often taught to answer binary questions, like, “Is there free fluid in the abdomen?”

Ultrasounds 50

Ultrasounds Documentation/Coding Radiology Radiology 50

Science Based Medicine

AUGUST 17, 2023

A new paper documents COVID-19 medical misinformation shared by US physicians on social media The post Examining COVID-19 misinformation propagated by US physicians first appeared on Science-Based Medicine.

Documentation/Coding 78

Documentation/Coding 78

EM Literature of Note

OCTOBER 9, 2024

while also relying upon finished human documentation for its “decision-support” The prompts – “should”/”does” – replicate the intent of the decision-support concept of the exploration, but not the retrospective nature of the content.

Radiology 84

Radiology Radiology Emergency Department Documentation/Coding 84

EM Ottawa

DECEMBER 28, 2023

There is a well-documented correlation amongst EMS and adult ED physicians who provide less pediatric care to […] The post Pediatric Traumatic Cardiac Arrest appeared first on EMOttawa Blog. Trauma is the leading cause of child and youth mortality globally (1). Pediatric trauma is a high acuity but low frequency event (2).

Pediatrics 78

Pediatrics Documentation/Coding EMS Wellness 78

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. If you take a history or examine a body part, document it. Temp is 98.7 and pulse 121.

Documentation/Coding 71

Documentation/Coding Hospitals Sepsis Infectious Diseases 71

Mind The Bleep

NOVEMBER 21, 2023

Unless you’re documenting something hilarious, please keep it brief and to the point. History of Presenting Complaint In this section use SOCRATES to document the pain. Drugs/Allergies When documenting drugs – try to get the dose and frequency (this can be found on Summary Care Records from the GP if you have access).

Documentation/Coding 52

Documentation/Coding COPD EKG/ECG Wellness 52

EMDocs

JUNE 13, 2024

We just don’t document it. If we don’t use printed instructions, document our verbal instructions regarding the most common side effects of the drug(s) being prescribed. Documenting our warnings should be standard care. Giving written instructions about a drug is the pharmacist’s job.

Documentation/Coding 77

Documentation/Coding Patient Safety Emergency Department Hospitals 77

American Medical Compliance

OCTOBER 3, 2024

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. Furthermore, staff members should be trained on the contents of these documents.

PPE 100

PPE Hazardous Materials Documentation/Coding Operations 100

EMDocs

OCTOBER 3, 2023

This is also where keeping up with documentation starts to slip. You’ll need to put the following tasks in a rank order list: new patient evaluations, dispositions, managing critical or potentially critical patients, results review, team huddle, running the board, calling consults, doing procedures, and documentation. It’s up to you.

Documentation/Coding 97

Documentation/Coding EMS Operations Emergency Department 97

EMDocs

OCTOBER 11, 2023

.” The tech cleans the wound and documents it as 2cm long and “ dirty.” The ED physician documents suturing a 3 cm laceration in a single layer, omitting any reference to any wound exploration, cleansing or debridement. I thought they were incidental “ bone islands” so I didn ’ t document them. Negligence was present.

Documentation/Coding 69

Documentation/Coding Radiology Radiology Patient Safety 69

Dr. Smith's ECG Blog

JUNE 13, 2024

Her first set of vitals were documented: BP 116/57 Pulse 94bpm Respiratory rate 24/min O2 sat 90% on room air Temp 97F She had been cleaning a Jeep in the sun, and was sunburned. The physician documented “normal sinus rhythm”. The physician documented that she was “improved” and the patient was discharged. CK MB was 1.9

EKG/ECG 89

EKG/ECG Documentation/Coding EMS Burns 89

The Trauma Pro

JULY 16, 2024

Typical options would be direct correspondence with a liaison for simple one-service issues or discussion (and good documentation) from a morbidity and mortality conference. Alternate review pathways There are more options for review other than the primary and secondary pathways mentioned in the previous paragraph.

Operations 147

Operations Documentation/Coding Pediatrics 147