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 94

Documentation/Coding Best Practices Operations Outcomes 94

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 110

Documentation/Coding Wellness Infectious Diseases EMS 110

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

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

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 100

PPE Hazardous Materials Documentation/Coding Operations 100

Ken Grauer, MD

JUNE 22, 2024

See ECG Blog #313 — as well as My Comment at the bottom of the page in the June 17, 2024 post in Dr. Smith's ECG Blog ). 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".

EKG/ECG 433

EKG/ECG Stroke Documentation/Coding Wellness 433

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

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 61

Documentation/Coding Administration Wellness 61

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 81

Documentation/Coding Emergency Department Best Practices Federal Emergency Management Agency 81

Mind The Bleep

NOVEMBER 21, 2023

” Yes, I have seen clerking look like this and I can confirm, it does not go down well. 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.

Documentation/Coding 52

Documentation/Coding COPD EKG/ECG Wellness 52

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

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 141

Pediatrics Documentation/Coding Burns Academics 141

American Medical Compliance

OCTOBER 25, 2024

Compliance isn’t just a box to check—it’s a vital responsibility that safeguards patient well-being and protects organizations from significant financial losses. Shockingly, over $54 billion is stolen each year through scams targeting patients and insurance companies with fraudulent medical charges, according to the NHCAA.

Documentation/Coding 84

Documentation/Coding Operations Best Practices Shock 84

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

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 95

Burns Documentation/Coding Wellness 95

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 88

Documentation/Coding Wellness 88

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

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 87

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 87

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 95

Best Practices PPE Infectious Diseases Documentation/Coding 95

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

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

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 115

EKG/ECG Documentation/Coding Wellness Resuscitation 115

EM Literature of Note

OCTOBER 1, 2023

” This brief report in Annals describes a retrospective experiment in which 30 written case summaries lifted from the electronic documentation system were fed to either clinician teams or ChatGPT. Each case was tested both solely on the recorded narrative, as well as with laboratory results added.

Documentation/Coding 86

Documentation/Coding Operations Emergency Department Wellness 86

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 52

Patient Safety Documentation/Coding Wellness 52

Total Medical ComplianceHIPAA

MARCH 15, 2023

This is causing concerns about the risk to the patient’s privacy as well as how to handle requests from the employers for more details. The HIPAA regulations are clear that an authorization document cannot include anything but another authorization. If the doctor believes this to be valid, they generate the letter.

Documentation/Coding 59

Documentation/Coding Wellness 59

Emergency Medicine Journal

JULY 24, 2023

Introduction Pain is the most common presenting feature within the ED, yet undertreatment of pain in the ED is a well-documented problem worldwide. Despite the development of interventions to address this problem, there is still limited understanding of how pain management can be improved within the ED.

Emergency Department 74

Emergency Department Documentation/Coding Research Wellness 74

Greater Sydney Area HEMS

AUGUST 1, 2023

Why does it work so well? When I found it, I felt the documentation (if done at all) largely tended to be the bare minimum, and certainly not reflective of the beautiful learning conversations happening in the room. – The re-design of C+C documentation process was launched. It also dovetails with our governance process.

Documentation/Coding 52

Documentation/Coding Outcomes Hospitals Administration 52

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.

Documentation/Coding 162

Documentation/Coding Fractures Hospitals Research 162

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 Documentation/Coding Fractures Hospitals 113

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 70

Ultrasounds Documentation/Coding Wellness EMS 70

Taming the SRU

FEBRUARY 22, 2024

M&M - Arterial Lines - Fat Embolism Syndrome - CPC Morbidity & Mortality WITH Dr. Finney Case 1: MVC AMA, especially in pediatrics, is a high-risk disposition that requires thorough discussion and documentation Approach pediatric blunt abdominal trauma with a thorough physical exam and consider decision making tools when applicable Case 2 & (..)

Pediatrics 81

Pediatrics Documentation/Coding Wellness 81

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 111

EKG/ECG Burns Urgent Care Documentation/Coding 111

Stop and Think

NOVEMBER 19, 2023

Also well known—from old data—was that myocarditis is a cause of cardiac arrest during sport. This was a 20-year survey in which the authors used 4 independent databases to document the incidence and causes of sudden cardiac death in NCAA athletes. Young males had the highest risk of this adverse effect. But it was real.

Documentation/Coding 128

Documentation/Coding Wellness Resuscitation 128

Total Medical ComplianceHIPAA

JUNE 12, 2024

Either reason must be well documented. The only reasons that OSHA would accept for not using the new device are as follows: The device is more likely to cause harm to the employee. Using the device for the procedure would put the patient at greater risk. HIPAA: Can a subpoena be ignored if we feel it will cause harm to the patient?

Documentation/Coding 52

Documentation/Coding Wellness 52

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

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 77

Stroke Administration Outcomes Documentation/Coding 77

Dr. Smith's ECG Blog

SEPTEMBER 12, 2024

The paramedic called the EM physician ahead of arrival and discussed the case and ECGs, and both agreed upon activating "Code STEMI" (even though of course it is not STEMI by definition), so that the acute LAD occlusion could be treated as fast as possible. So the cath lab was activated.

EKG/ECG 119

EKG/ECG EMS Documentation/Coding Shock 119