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. Learn: If you do know the patient, this is a great learning opportunity as well as making the call quicker and providing good continuity of care. If not, ask for your seniors help.

Radiology 98

Radiology Radiology Documentation/Coding Hospitals 98

ACEP Now

NOVEMBER 7, 2024

Conclusion Poorly healing wounds pose a significant burden on health care systems and personal well-being, and their presence as a harbinger of severe morbidity and mortality must be appreciated. Photographic documentation of the wound is helpful to enhance continuity of care.

Burns 97

Burns Documentation/Coding Outcomes Emergency Department 97

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 He looks well by ED standards. and malaise. He has no urinary or bowel symptoms. His past medical history is unremarkable. After a focused history and physical examination, you narrow the differential to diverticulitis.

Documentation/Coding 115

Documentation/Coding Wellness Infectious Diseases EMS 115

Ken Grauer, MD

FEBRUARY 28, 2023

Figure-2: I've color-coded P waves from Figure-1 according to P wave morphology ( See text ). NOTE: For clarity — I've color-coded P waves in the long lead II rhythm strip according to morphology. Remember — 12 leads are better than one! Microvascular dysfunction — cardiac vasculitis — intravascular thrombosis.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

American Medical Compliance

MARCH 11, 2024

These are recordkeeping and documentation. While the primary focus in dentistry is patient health and well-being, carefully keeping records is equally needed. Informed Consent Documentation Before initiating any treatment, informed consent must be obtained from the patient or their legal guardian.

Documentation/Coding 105

Documentation/Coding Best Practices Operations Outcomes 105

Stop and Think

JULY 17, 2024

Reading only the guidelines is not enough, because guideline documents are merely one group’s take of the seminal trials. I often advise young learners to break away from, say, learning how to measure the left atrial appendage, and spend some time reading the seminal trials.

Wellness 74

Wellness Academics Documentation/Coding 74

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

Sensible Medicine

DECEMBER 18, 2023

Now let’s compare the two documents. That is my conclusion as well, and I favor large, pragmatic randomized trials in adults and kids with staggered starting times (adults first — to protect kids from harms we may not yet know). From their document. The AAP champions surgery and medications. Better food?

Pediatrics 145

Pediatrics Documentation/Coding Burns Academics 145

Mind The Bleep

FEBRUARY 2, 2025

Here we assume you know the basics , and instead we focus on the common pitfalls with tips on how to be safe & well reasoned. Have a proforma so you don’t miss things Save a proforma (if electronic documentation ) or print one out.

Dehydration 97

Dehydration Documentation/Coding Wellness 97

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

EMDocs

AUGUST 22, 2024

13 Interventions may include: Ascertaining a patient’s preferred language early in the clinical encounter (during registration, for instance), and clearly documenting this preference in a place that is visible to all providers. Well-meaning providers who are not highly fluent may contribute to miscommunication and diagnostic errors.

Documentation/Coding 104

Documentation/Coding Emergency Department Federal Emergency Management Agency Best Practices 104

Ken Grauer, MD

JULY 29, 2023

The "good news" — is that we clearly see sinus P waves in ECG #1 , that document conversion to sinus rhythm ( ie, upright P waves in lead II that precede each QRS complex with a constant and normal PR interval ). This young woman did well for a year — but unfortunately suffered another cardiac arrest, from which she could not be resuscitated.

EKG/ECG 370

EKG/ECG Resuscitation Documentation/Coding Hospitals 370

Stop and Think

JANUARY 1, 2024

Well, that can be a problem. Sometimes things we do are well grounded in evidence. Things like reading ECGs, echocardiograms, as well as learning to do procedures. Well, do you know the actual trials underpinning this evidence? They sit in a Google document. It will be a working document.

Documentation/Coding 98

Documentation/Coding Wellness EKG/ECG Hospitals 98

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 83

Pediatrics Documentation/Coding EMS Wellness 83

American Medical Compliance

OCTOBER 3, 2024

As dental professionals, it’s crucial to understand and adhere to OSHA dental compliance standards to ensure the well-being of both staff and patients. 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

PEMBlog

MARCH 4, 2025

Well cover its clinical presentation, epidemiology, diagnostic approach, and management, including why standard beta-lactam antibiotics wont work. Plus, well discuss whether M. Studies supporting antibiotic treatment of documented mycoplasma pneumoniae in children are limited.

Pediatrics 94

Pediatrics Military CDC Hospitals 94

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 75

Documentation/Coding Administration Wellness 75

The Skeptics' Guide to EM

JANUARY 25, 2025

ROC curves help clinicians determine how well a test or model can differentiate between patients with and without a condition. P-hacking is not exclusive to AUC but is a well-documented problem in broader research, particularly surrounding the 0.05 p-value significance threshold.

Research 49

Research EMS Documentation/Coding Operations 49

Sensible Medicine

MAY 16, 2024

This works reasonably well. They documented that these patients had high vagal tone. A few short words about our conversation: Two decades have passed and electrophysiologists have learned little about how to ablate atrial fibrillation. Now, and then, we simply ablate circles around the orifices of the pulmonary veins.

Documentation/Coding 100

Documentation/Coding Wellness 100

Total Medical ComplianceHIPAA

AUGUST 15, 2024

Document what worked well and what did not. Clear Communication Channels : Confirm that communication channels are well-defined and tested. Documentation and Compliance Comprehensive Documentation : Maintain detailed documentation of the DRP, including all tests, training sessions, and updates.

Documentation/Coding 59

Documentation/Coding Best Practices Risk Management Wellness 59

Dr. Smith's ECG Blog

MARCH 4, 2024

I have often written about how an ECG interpreted as "normal" by a conventional algorithm may well be manifesting OMI, or even long QT or hyperkalemia. link] Or use the QR code: 10 Cases: Case 1 Do you want to be interrupted to view what the computer calls normal or nonspecific ECGs? 2 cases at once! You can use it an unlimited amount.

EKG/ECG 128

EKG/ECG Documentation/Coding Wellness Resuscitation 128

American Medical Compliance

AUGUST 14, 2024

This training not only raises awareness but also empowers dental teams to take action, ensuring that they can contribute to the safety and well-being of their patients. ” This broad definition underscores the variety of ways in which a child’s well-being can be compromised.

Burns 105

Burns Documentation/Coding Wellness 105

American Medical Compliance

AUGUST 7, 2024

It protects the health and well-being of staff. For example, CMS requires accurate and timely documentation of patient care to ensure proper billing and reimbursement. This plan should clearly define your policies and procedures regarding patient privacy, billing, documentation, and safety.

Hazardous Materials 105

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 105

Dr. Smith's ECG Blog

JANUARY 5, 2024

The documentation does not describe any additional details of the history. They also documented "Reproducible chest tenderness." The proximal LAD has mild disease, but the distal LAD and diagonal branches are not well evaluated in this view. The distal LCx is seen, and the OM is not well visualized here.

EKG/ECG 121

EKG/ECG Burns Urgent Care Documentation/Coding 121

American Medical Compliance

AUGUST 29, 2024

Just like medical errors, falls are preventable incidents that require careful monitoring, proper safety protocols, and prompt interventions to minimize risk and protect patient well-being. Understanding this definition helps healthcare providers recognize the importance of fall prevention as a critical aspect of patient safety.

Patient Safety 98

Patient Safety Documentation/Coding Wellness 98

EMDocs

JUNE 8, 2023

and 9 hours of symptom onset; stroke symptoms that started during sleep were assumed to have started halfway between the actual last known well and the time of wake-up. Subsequently reduced enrollment to 310 patients because no patients had been lost to follow-up or had insufficient data documented.

Stroke 98

Stroke Administration Documentation/Coding Outcomes 98

American Medical Compliance

FEBRUARY 17, 2024

Ensuring the safety and well-being of both patients and staff is paramount. Maintain Comprehensive Recordkeeping Document workplace injuries and illnesses.

Best Practices 105

Best Practices PPE Infectious Diseases Documentation/Coding 105

ACEP Now

DECEMBER 6, 2024

This case report documents the first known instance of using NTG during an emergency department resuscitation to treat a patient in cardiac arrest due to severe coronary artery vasospasm. Cardiac arrest secondary to myocardial ischemia from coronary vasospasm is well documented.

Resuscitation 98

Resuscitation EKG/ECG Documentation/Coding COPD 98

EMDocs

DECEMBER 4, 2023

The Wells’ Criteria for DVT can help risk stratify [2,3]. If the patient’s Wells score is ≤ 0, DVT is nearly clinically excluded and no further immediate lab or ultrasound is necessary. In patients with a Wells’ score of 1-2 (moderate risk), DVT can be ruled out with a negative d-dimer rather than an US. mg/kg for 24 hours.

Ultrasounds 96

Ultrasounds Documentation/Coding Wellness EMS 96

Dr. Smith's ECG Blog

OCTOBER 18, 2023

4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5] Am J Emerg Med. 2022 ; 55 : 180 - 182 6.

EKG/ECG 119

EKG/ECG Documentation/Coding Emergency Department Outcomes 119

ACEP Now

OCTOBER 3, 2023

This document is an update of guidelines first published in 2000, and then updated in 2007. Confounders to the GCS such as seizure and post-ictal phase, ingestions and drug overdose, as well as medications administered in the prehospital setting that impact GCS score should be documented. 2019;154(7):e191152.

Fluid Resuscitation 98

Fluid Resuscitation Documentation/Coding Resuscitation EMS 98

The Trauma Pro

DECEMBER 26, 2023

Screening looks at patient factors such as age, obesity, and previous VTE, as well as injury risk factors like spine and pelvic fractures and decreased mobility. But the key fact is that every compression device manufacturer includes existing DVT as a contraindication in their product documentation.

Fractures 124

Fractures Documentation/Coding Hospitals Research 124

Sensible Medicine

AUGUST 16, 2024

I’d been certain that all would be well in medicine in the age of AI. Both have done well, the woman after a percutaneous coronary intervention, the man after a few days without contact with the medical field). I saw how good AI can be at documenting a history taken by a doctor. So, what changed my thinking. “ 2.

Documentation/Coding 121

Documentation/Coding Wellness 121

Sensible Medicine

APRIL 29, 2024

You can assess how well (or poorly) a practicing cardiologist did analyzing a paper in the Journal of Clinical Epidemiology. In this section, they documented the variations in analytic method (for instance, the choice of model and co-variates). It’s the Methods ! Allow me an experiment this week.

Stroke 142

Stroke Documentation/Coding Shock Research 142

Pediatric EM Morsels

JULY 5, 2024

We collected data directly from the bedside clinician which enabled us to gather pertinent patient symptoms and physical examination findings that may not be well documented in the medical record, but more accurately identify the child’s injuries.”

Pediatrics 164

Pediatrics Head Injuries Dislocations Research 164

The Trauma Pro

OCTOBER 31, 2023

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. Contact the trauma medical director, service chief, or hospital administrator and see if they can intervene.

Risk Management 113

Risk Management Fractures Documentation/Coding Hospitals 113

Total Medical ComplianceHIPAA

APRIL 14, 2023

You can be sure that your patient has been notified of the subpoena if you have a judge-signed subpoena, an authorization signed by the patient, or an attorney signed document that states this process has already happened. You can even call and talk to your patient and document this.

Documentation/Coding 83

Documentation/Coding Outcomes Wellness 83