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 429

EKG/ECG Stroke Documentation/Coding Wellness 429

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

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

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

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

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

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

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

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 87

Documentation/Coding Best Practices Operations Outcomes 87

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 108

Documentation/Coding Wellness Infectious Diseases EMS 108

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

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 90

Documentation/Coding 90

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 100

Documentation/Coding 100

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 84

Elder Abuse Emergency Department Documentation/Coding Hospitals 84

Pediatric EM Morsels

FEBRUARY 2, 2024

In one ED study, ALL cases of missed travel-related illness did not have a documented travel history in their ED note , whereas 90% of the identified travel-related illnesses had a provider documented travel history (Greenky 2022) Those who are visiting friends and relatives (VFR) are typically at highest risk.

Infectious Diseases 161

Infectious Diseases Pediatrics Sepsis Documentation/Coding 161

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

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 92

Documentation/Coding Leadership Best Practices Outcomes 92

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

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 82

Documentation/Coding Hospitals Patient Safety Emergency Department 82

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 132

Pediatrics Documentation/Coding Burns Academics 132

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 98

Documentation/Coding EMS Operations Emergency Department 98

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

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 82

Pediatrics Documentation/Coding EMS Wellness 82

The Trauma Pro

JUNE 20, 2023

Documentation provided by the nurse or other providers in the medical record must demonstrate that they were in some way involved in care of the patient. Following are the basics of malpractice as it relates to nurses. A scope of duty must be established within the relationship.

Documentation/Coding 130

Documentation/Coding Operations Hospitals 130

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 75

CDC Documentation/Coding Research Wellness 75

RebelEM

MAY 15, 2023

Frantically look through the assisted care documents for do-not-resuscitate paperwork Place a chest tube on the left side Place a chest tube on the right side Start noninvasive or mechanical ventilation FOR THE RIGHT ANSWER CLICK ON THE ROSH REVIEW LOGO BELOW References: Dixon A. The patient’s emergent portable chest X-ray is shown below.

EMS 96

EMS Documentation/Coding Resuscitation 96

Stop and Think

JANUARY 1, 2024

They sit in a Google document. It will be a working document. We’ve already written many of these reviews. It would take another year to finish. Our change of heart happened recently. We’ve decided to write this book on Substack. One review at a time. They will come out as separate posts.

Documentation/Coding 98

Documentation/Coding Wellness EKG/ECG Hospitals 98

PulmCCM

JANUARY 29, 2024

Read the document for all the details (it’s not long). In accordance with the fraught ethical and emotional factors surrounding organ donation, this section is the tersest, least explicated section of the document. PulmCCM is not affiliated with the American Heart Association. Here’s PulmCCM’s take on the new changes.

Seizures 115

Seizures CPR Documentation/Coding Hyperthermia / Hypothermia 115

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 88

EKG/ECG Documentation/Coding EMS Burns 88

Dr. Smith's ECG Blog

NOVEMBER 25, 2024

The guide is a living document, which I (Willy Frick) will continuously update as I encounter additional angiographic images worth learning from. Attaining expertise in angiography requires dedication and practice. What follows is an introduction to angiography -- a guide meant for people with no prior experience interpreting angiograms.

Documentation/Coding 98

Documentation/Coding EKG/ECG 98

American Medical Compliance

NOVEMBER 8, 2024

Proper injury reporting protects patients, supports a safe workplace, and shields healthcare providers from potential legal issues that may arise due to negligence or lack of documentation. Scenario-based training adds real-world relevance.

Documentation/Coding 84

Documentation/Coding Legal Issues Operations Incident Reporting 84

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

MAY 7, 2024

I’ve simplified the Cribari Grid calculation process as much as possible and have provided a Microsoft Word document that automates the task. If so, you may need to add a new activation criterion. Then, count that patient as undertriage, of course. You’ve got your numbers!

Documentation/Coding 113

Documentation/Coding 113

Pediatric EM Morsels

JULY 28, 2023

A critical MORSEL is that every child you treat for DKA needs to have an initial thorough neuro exam including cranial nerves and then frequent neuro reassessments … and document it ( so your colleagues who take over care for the kid can know if there has been a change )!

Fluid Resuscitation 246

Fluid Resuscitation Pediatrics Resuscitation Research 246

Northwestern EM Blog

JULY 22, 2024

Tandlich, M. 2024, Jul 22).Posterior Posterior Reversible Encephalopathy Syndrome (PRES) [NUEM Blog.

Seizures 97

Seizures Documentation/Coding Hospitals 97

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