EMDocs

JUNE 28, 2023

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. EMS report includes concern for CVA, with variable documentation of face and extremity weakness. Nursing documentation includes the presence of a facial droop.

Documentation/Coding 69

Documentation/Coding EMS Stroke Patient Safety 69

AENJ: Current Issue

SEPTEMBER 30, 2023

Pressure injuries (PIs) are an important quality and patient safety metric for health care organizations. A team at a Level 1 trauma center recognized the need for ED-friendly documentation and a validated ED skin risk assessment instrument. PI monitoring and treatment are often overlooked in the emergency department (ED).

Emergency Department 75

Emergency Department Patient Safety Documentation/Coding Research 75

American Medical Compliance

AUGUST 7, 2024

Patient safety is a critical concern, with the World Health Organization (WHO) estimating that 1 in 10 patients is harmed while receiving healthcare. Compliance with healthcare regulations is crucial not only for avoiding legal repercussions but also for ensuring high standards of patient care and safety.

Hazardous Materials 80

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 80

EMDocs

OCTOBER 10, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. Exam is normal except for tenderness as documented in the diagram. She never had a documented abdominal exam. I just failed to document it. Stories of med mal lawsuits can save lives.

Documentation/Coding 76

Documentation/Coding Hospitals Sepsis Infectious Diseases 76

EMDocs

APRIL 18, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. The admitting nurse documents an “OTJ injury” with a chief complaint of “My boss made me come.” To opt in to the free subscriber list, click here. Stories of med mal lawsuits can save lives.

Patient Safety 89

Patient Safety Hospitals Documentation/Coding EMS 89

American Medical Compliance

AUGUST 29, 2024

Understanding this definition helps healthcare providers recognize the importance of fall prevention as a critical aspect of patient safety. Healthcare providers must act in the best interest of their patients by promptly recognizing injuries, accurately documenting them, and reporting incidents to prevent further harm.

Patient Safety 70

Patient Safety Documentation/Coding Wellness 70

EMDocs

JANUARY 25, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. The patient’s last INR should be documented, and one obtained if not recent. For patients on warfarin, documenting a reason for not checking an INR is a worthwhile practice.

Poisoning 73

Poisoning Documentation/Coding Patient Safety Hospitals 73

Mind The Bleep

JULY 26, 2023

Good Medical Practice is the GMC’s core guidance document (a new version is out this year) and there are supporting documents covering important areas like consent , confidentiality , prescribing and treating children. Take care to document these discussions in the records. Most employers will have a chaperones policy too.

Documentation/Coding 52

Documentation/Coding Patient Safety Wellness Hospitals 52

American Medical Compliance

FEBRUARY 9, 2024

They conduct internal audits and reviews to ensure adherence to regulations and recommend corrective actions when necessary. Reporting and Documentation Accurate record-keeping is a cornerstone of compliance. Compliance officers maintain detailed records of compliance activities, investigations, and corrective actions.

Operations 69

Operations Best Practices Patient Safety Documentation/Coding 69

American Medical Compliance

JULY 2, 2024

Instances of Unprofessional Behavior Instances of unprofessional conduct in healthcare can undermine patient safety, cause distrust, and negatively impact team dynamics. Document observations consistently to identify patterns and trends over time. To become certified, please visit us at: American Medical Compliance (AMC).

Patient Safety 66

Patient Safety Documentation/Coding Outcomes Wellness 66

American Medical Compliance

DECEMBER 6, 2023

Elopement is defined by the VA National Center for Patient Safety (NCPS) as when a patient knows they are not allowed to leave but yet chooses to do so consciously. Finding out that a patient has “gone missing” is a terrifying experience for both clinicians and patients’ families.

Patient Safety 52

Patient Safety Documentation/Coding Hospitals 52

ACEP Now

MARCH 13, 2024

Emergency departments (EDs) provide the essential service of evaluating patients with unscheduled, acute, undifferentiated, and decompensated conditions. Consequences of this are well documented and include delayed treatment, exposure to error, increased length of stay, and increased mortality. ED crowding impairs this mission.

Ethical Issues 52

Ethical Issues Emergency Department Operations Hospitals 52

EB Medicine

MAY 3, 2019

Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient.

Emergency Department 40

Emergency Department Psychiatric Documentation/Coding Outcomes 40

EB Medicine

JULY 8, 2019

Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Patients typically take vitamins postoperatively to prevent such complications. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: Nutritional deficiencies are also common complications. Metabolism.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

The Skeptics' Guide to EM

MARCH 22, 2019

Most emergency physicians use some form of electronic medical records (EMRs) when seeing patients. The EMR tasks we undertake are expanding rapidly, far beyond simply documenting history and physical examination and every implementation slows us down. Research by Hill et al (1) demonstrated that an ED shift can have 4,000 clicks.

Emergency Department 52

Emergency Department Documentation/Coding Dislocations Research 52