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 290

Documentation/Coding Outcomes Hospitals Wellness 290

American Medical Compliance

JANUARY 9, 2024

The following Documentation and Provider Standards Training educates healthcare providers on the significance of documentation compliance in healthcare. Documentation Guidelines and Standards The legal system views documentation as a fundamental component.

Documentation/Coding 52

Documentation/Coding Risk Management Research 52

University of Maryland Department of Emergency Med

SEPTEMBER 22, 2023

Since the switch from fee for service to value based care in the US, there has been a marked push to improve our documentation to expand ou. Click to view the rest

Documentation/Coding 58

Documentation/Coding Emergency Department 58

Ken Grauer, MD

JUNE 22, 2024

I cannot tell you how many times such "written" documentation was off, due to the tendency to inscribe a normal number instead of counting for 30 seconds because "the patient looked like they were breathing normally". KEY Point: The respiratory rate that is written on the chart does not count!

EKG/ECG 433

EKG/ECG Stroke Documentation/Coding Wellness 433

ACEP Now

MARCH 10, 2025

Some erroneously believe that merely documenting a patient leaving AMA, using an AMA form, is sufficient to meet legal and ethical standards. Proper documentation of AMA is essential to documentation, and also can confer medicolegal protection. Dr. Marco is professor of emergency medicine at Penn State Health-Milton S.

Documentation/Coding 52

Documentation/Coding Emergency Department Psychiatric Risk Management 52

Mind The Bleep

FEBRUARY 2, 2025

Your response may range from simply documenting the event somewhere secure, so that you have a contemporaneous record of what happened and who else may have been involved to support any future decisions you might make, all the way up to formally speaking up. It is hard to speak up sometimes.

Documentation/Coding 98

Documentation/Coding Outcomes Burns Wellness 98

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

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 138

Documentation/Coding 138

ACEP Now

DECEMBER 17, 2024

One of the first documented strikes among house staff officers took place in 1974 at Howard University here in Washington, D.C., Historically, labor unionization among health care workers is uncommon, 5 including among resident physicians, 6 and the prospect of striking even more so.

Burns 105

Burns Hospitals Documentation/Coding Emergency Department 105

Mind The Bleep

FEBRUARY 2, 2025

Don’t panic: If you are the only available person and dont know the patient, document the information in the notes and let your senior know. Again, document the call clearly, discuss with your senior and implement further investigations/treatment as appropriate. If not, ask for your seniors help.

Radiology 98

Radiology Radiology Documentation/Coding Hospitals 98

University of Maryland Department of Emergency Med

NOVEMBER 2, 2023

BACKGROUND: Prehospital (EMS) clinicians are positioned on the front lines of health care. With respect to stroke identification and treatment, ea. Click to view the rest

Stroke 64

Stroke Documentation/Coding EMS 64

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 201

EMS Documentation/Coding 201

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 Emergency Department 130

PEMBlog

NOVEMBER 21, 2024

Deb Hsu, MD, MEd – Division Director, Stanford Documenting feedback: Facilitate trainee growth and ensure program accreditation Discussed structuring feedback to ensure trainees and faculty receive actionable insights for growth while providing programs with documented evidence of this feedback to meet accreditation requirements.

Documentation/Coding 52

Documentation/Coding Pediatrics Emergency Department 52

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 105

Documentation/Coding Best Practices Operations Outcomes 105

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 113

Documentation/Coding Best Practices 113

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 104

Documentation/Coding Hospitals Patient Safety Emergency Department 104

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 115

Documentation/Coding Wellness Infectious Diseases EMS 115

Mind The Bleep

FEBRUARY 2, 2025

If the aim is for someone to take over care then an explanation of why they can provide better care often works better than why you can’t look after them Outline the purpose of your referral early.

Radiology 96

Radiology Radiology Sepsis Documentation/Coding 96

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

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 122

Documentation/Coding EMS Operations Emergency Department 122

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 105

Documentation/Coding Leadership Best Practices Outcomes 105

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 104

Seizures Dehydration Documentation/Coding Infectious Diseases 104

ACEP Now

NOVEMBER 7, 2024

Photographic documentation of the wound is helpful to enhance continuity of care. Social determinants, such as a history of poor medication compliance, housing insecurity, lack of a support system and transportation resources, comorbidities, or need for vascular intervention, may necessitate inpatient admission.

Burns 97

Burns Documentation/Coding Outcomes Emergency Department 97

RebelEM

NOVEMBER 6, 2024

Elbow Dislocation Definition: Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology: Incidence Second most common joint dislocation (after shoulder) in adults Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow ( Cohen 1998 ) Posterolateral is the most common type of dislocation (..)

Dislocations 114

Dislocations Fractures Soft Tissue Injuries Outcomes 114

Emergency Medicine Journal

DECEMBER 30, 2024

Unclear ED processes for receiving, documenting and sharing information about pre-alerts increased the risk of information loss. Variation in ED response was influenced by individual and organisational factors, particularly the resources available at the time of pre-alert.

Emergency Department 52

Emergency Department Stroke Documentation/Coding Outcomes 52

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 87

Elder Abuse Emergency Department Documentation/Coding Hospitals 87

PulmCCM

JANUARY 15, 2025

Draft Guidance Document Wong et al. References Pulse Oximeters for Medical Purposes - Non-Clinical and Clinical Performance Testing, Labeling, and Premarket Submission Recommendations. Draft Guidance for Industry and Food and Drug Administration Staff. January 2025.

Academics 81

Academics Documentation/Coding Administration Research 81

Sensible Medicine

DECEMBER 18, 2023

Now let’s compare the two documents. From their document. The USPSTF has issued draft guidance that emphasizes diet and exercise. The AAP champions surgery and medications. I have been critical of the AAP’s endorsement — a topic I discussed here. Let’s take a look at the USPSTF. This is Orwellian.

Pediatrics 145

Pediatrics Documentation/Coding Burns Academics 145

EMDocs

JUNE 28, 2023

EMS report includes concern for CVA, with variable documentation of face and extremity weakness. Nursing documentation includes the presence of a facial droop. There, his initial neuro exam is documented as normal, but a head CT reveals evidence of a possible acute CVA in the right hemisphere.

Documentation/Coding 94

Documentation/Coding EMS Stroke Patient Safety 94

Mind The Bleep

FEBRUARY 2, 2025

Have a proforma so you don’t miss things Save a proforma (if electronic documentation ) or print one out. Be reassured that this gets easier with time and take satisfaction from becoming more confident with the more frequent and straightforward presentations, such as community-acquired pneumonia.

Dehydration 97

Dehydration Documentation/Coding Wellness 97

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

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

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 98

Documentation/Coding Patient Safety Emergency Department Hospitals 98

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 93

Documentation/Coding Radiology Radiology Patient Safety 93

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

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