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

The Trauma Pro

MARCH 14, 2024

They can range from very spacious… to very tight… Most trauma bays that I have visited were somewhere between 225 and 300 square feet (21-28 sq meters), although some were quite large (Rashid Hospital in Dubai at nearly 50 sq meters!). Related link: Facilities Guidelines Institute documents

Resuscitation 162

Resuscitation Documentation/Coding Hospitals 162

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 89

Elder Abuse Emergency Department Documentation/Coding Hospitals 89

PEMBlog

MARCH 4, 2025

Garcia T, Florin TA, Leonard J, Shah SS, Ruddy RM, Wallihan R, Desai AP, Alter S, El-Assal O, Marzec S, Keaton M, Yun KW, Leber AL, Mejias A, Cohen DM, Ramilo O, Ambroggio L; Childrens Hospitals Initiative for Research in Pneumonia (CHIRP). Studies supporting antibiotic treatment of documented mycoplasma pneumoniae in children are limited.

Pediatrics 94

Pediatrics Military CDC Hospitals 94

ACEP Now

JANUARY 11, 2024

The wave of increasing hospital closures and service line cutbacks continues to sweep the United States. A recent article documents 56 additional U.S. hospitals that are closing clinical departments or ending or reducing services. 2 Of these 56 additional hospitals, many are not rural; thus, this specter is expanding.

Hospitals 52

Hospitals Administration Documentation/Coding Research 52

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). The only gray zone is the score of 4 or 5.

Documentation/Coding 147

Documentation/Coding Emergency Department Hospitals 147

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. He is transported to a different hospital as possible trauma. A lawsuit is filed against the first hospital and ED physician.

Documentation/Coding 93

Documentation/Coding EMS Stroke Patient Safety 93

EMDocs

JUNE 13, 2024

An attorney is consulted, and a lawsuit is filed against the EP, the hospital, the pharmacy, and the dentist. We just don’t document it. Result : Pre-trial settlement against the hospital and EP for a minimal amount. Documenting our warnings should be standard care. difficile enterocolitis. difficile colitis.

Documentation/Coding 98

Documentation/Coding Patient Safety Emergency Department Hospitals 98

EMDocs

AUGUST 22, 2024

3,4 Notably, institutions receiving federal funding (such as hospitals receiving Medicare reimbursement) must abide by Title VI of the 1964 Civil Rights Act, which entitles persons with NELP to language assistance. Utilizing certified interpreters and documenting their use. Educating patients on their rights. Lion KC, et al.

Documentation/Coding 104

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

Northwestern EM Blog

JULY 22, 2024

Tandlich, M. 2024, Jul 22).Posterior Posterior Reversible Encephalopathy Syndrome (PRES) [NUEM Blog. Expert Commentary by Maas, MB]. Retrieved from [link] Other Posts You May Enjoy

Seizures 97

Seizures Documentation/Coding Hospitals 97

EMDocs

JUNE 9, 2023

How do we manage the agitated child in the pre-hospital environment? After listening to this episode you will be able to: Identify unique aspects of the pre-hospital environment that impact assessment and treatment of agitated children Describe the role of EMS personnel and EMS director in the care of agitated children. mg/kg IN; 0.1-0.15

EMS 98

EMS Documentation/Coding Pediatrics Psychiatric 98

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. The exact duties may vary somewhat geographically and even between individual hospitals. Following are the basics of malpractice as it relates to nurses.

Documentation/Coding 130

Documentation/Coding Operations Hospitals 130

EMDocs

APRIL 18, 2024

He arrives in the ED of his small community hospital about 30 minutes later. The admitting nurse documents an “OTJ injury” with a chief complaint of “My boss made me come.” He arrives, admits the patient and spends the rest of the night in the hospital monitoring the patient’s condition. Right now!”

Patient Safety 105

Patient Safety Hospitals Documentation/Coding EMS 105

Don't Forget the Bubbles

MARCH 19, 2024

This has coincided with a widespread shortage of specialist placements for children facing behavioural, psychiatric, and child protection challenges, leading to an over-reliance on the placement of these children in hospitals. A paediatric social admission is one where a child is admitted to the hospital but not for a medical reason.

Hospitals 52

Hospitals Psychiatric Documentation/Coding Pediatrics 52

The Trauma Pro

JULY 13, 2023

Inclusion of extraneous information from later in the hospital stay. Lack of accurate team arrival documentation. Which ultimately means that you (this really means your hospital) will have to pay for more registrars / PI coordinators / nurses! Reams of paper, typically 20-30 pages. Ebola screens. Sepsis score.

Sepsis 100

Sepsis Documentation/Coding Hospitals 100

The Trauma Pro

OCTOBER 31, 2023

If you believe that harm will occur, here are your options, from least to most damaging to your professional status at the hospital: Contact another consultant in the same or overlapping specialty (if there is one). 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

The Trauma Pro

DECEMBER 26, 2023

Everyone knows that venous thromboembolism (VTE) is a potential problem in hospitalized patients, and especially so in trauma patients. But the key fact is that every compression device manufacturer includes existing DVT as a contraindication in their product documentation. And we probably won’t, ever.

Fractures 124

Fractures Documentation/Coding Hospitals Research 124

Stop and Think

JANUARY 1, 2024

My friend Dr. Andrew Foy had this idea: during rounds in the hospital with learners, Foy noticed that many things get done (drugs prescribed, tests ordered) as a matter of culture or history. They sit in a Google document. It will be a working document. As in…we do this because that is what we do. One review at a time.

Documentation/Coding 98

Documentation/Coding Wellness EKG/ECG Hospitals 98

Dr. Smith's ECG Blog

MARCH 19, 2024

This case was sent by Amandeep (Deep) Singh at Highland Hospital, part of Alameda Health System. The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB.

EKG/ECG 111

EKG/ECG Hospitals Documentation/Coding Outcomes 111

The Skeptics' Guide to EM

JULY 27, 2024

Ann Emerg Med 2024 Date: July 25, 2024 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: Your hospital is running Morbidity and Mortality (M&M) rounds after a few recent cases in which the diagnosis of sepsis was identified late, and antibiotics were delayed.

Sepsis 99

Sepsis Outcomes Documentation/Coding Hospitals 99

ACEP Now

DECEMBER 6, 2024

1 Relatively little literature on the clinical characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) patients complicated by coronary vasospasm exists beyond anecdotal reports, however. Cardiac arrest secondary to myocardial ischemia from coronary vasospasm is well documented. Angina pectoris. 1959;27:375-388.

Resuscitation 98

Resuscitation EKG/ECG Documentation/Coding COPD 98

PulmCCM

JANUARY 6, 2025

With financial penalties coming for noncompliance with the new rule, hospital administrators rapidly deployed the alerts to fire on all eligible inpatients. The SCREEN Trial SCREEN was a stepped-wedge cluster randomized trial of an EMR alert for organ failure, conducted at 45 wards of 5 hospitals in Saudi Arabia from 2019 to 2021.

Sepsis 45

Sepsis Documentation/Coding Hospitals Outcomes 45

EMDocs

JANUARY 25, 2024

An attorney is consulted and a lawsuit filed against the first two EP’s, the radiologist, and the hospital, claiming that the patient was negligently cared for during the first ED visit. Hospital : The nurse drew a full “rainbow” set of blood tubes. The patient’s last INR should be documented, and one obtained if not recent.

Poisoning 97

Poisoning Documentation/Coding Patient Safety Hospitals 97

EMDocs

SEPTEMBER 30, 2024

Among patients with a primary provider documented in the chart, 30-day outpatient follow-up rate was 21.3% (n = 313). The primary outcome was hospital admission rates. For the primary comparison, ICS + SCS reduced the risk of hospital admission compared with SCS; fixed-effects odds ratio (95% confidence interval) 0.73 (0.57-0.94).

Outcomes 105

Outcomes Academics Documentation/Coding Emergency Department 105

Emergency Medicine Journal

MAY 23, 2023

Background Whether and how bystander cardiopulmonary resuscitation (CPR) modifies the cardiac rhythm after out-of-hospital cardiac arrest (OHCA) over time remains unclear. The first documented cardiac rhythm was compared between patients who received bystander CPR and those who did not, using a 1:2 propensity score-matched analysis.

Resuscitation 40

Resuscitation CPR Hospitals Documentation/Coding 40

Ken Grauer, MD

FEBRUARY 28, 2023

Although acute Myocarditis is often suspected as the cause of troponin elevation in Covid-positive patients — documented viral myocarditis caused by Covid appears to be much less common than initially thought ( Up-to-Date — Caforio et al — Jan, 2023 ). Microvascular dysfunction — cardiac vasculitis — intravascular thrombosis.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

American Medical Compliance

MARCH 18, 2024

Although anyone working at a hospital can be a victim of violence, nurses and aides who have the most direct contact with patients are especially vulnerable. To become certified, please visit us at: American Medical Compliance (AMC). Reach out for other courses by visiting the AMC Course Library. Who is at Risk for Workplace Violence?

Psychiatric 95

Psychiatric Documentation/Coding Hospitals 95

American Medical Compliance

AUGUST 7, 2024

For example, CMS requires accurate and timely documentation of patient care to ensure proper billing and reimbursement. Adhering to CMS quality measures, such as reducing hospital readmission rates and improving patient safety protocols, helps maintain high standards of care.

Hazardous Materials 105

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 105

Sensible Medicine

APRIL 12, 2024

Most of my undergraduate medical education took place at New York Hospital, where a medical error occasioned the first calls for duty hour reform. I was responsible for staying at the bedside of (or at least in the hospital with) my patients until they were stable. PR was admitted to my service at a hospital where I briefly attended.

Radiology 83

Radiology Radiology Hospitals Documentation/Coding 83

Clinical Correlations

NOVEMBER 1, 2024

By Chloe Fong Peer Reviewed The correlation between vitamin deficiency and alcohol use disorder (AUD) has been well documented in the literature, with a study from 1963 finding that 70% of patients admitted to the hospital.

Documentation/Coding 52

Documentation/Coding Hospitals Wellness 52

EMDocs

FEBRUARY 13, 2024

If tomorrow, CMS came out with a new pay-for-performance metric that tied hospital reimbursement with clinician work satisfaction, what do you think would happen? The hospital would move heaven and earth to improve your satisfaction scores. Maybe your group or hospital has something to this effect and, if so, embrace it.

Emergency Department 97

Emergency Department Documentation/Coding Hospitals Wellness 97

PulmCCM

FEBRUARY 5, 2024

You can read the document here. Depends On the Patient, and Who You Ask The Centers for Disease Control and Prevention defines a fever (for general hospitalized patients) as >38°C. Read the original document here. Please comment below if you have any suggested additions or edits to this document. °C (100.9°F).

Best Practices 111

Best Practices Ultrasounds Infectious Diseases Sepsis 111

Don't Forget the Bubbles

NOVEMBER 20, 2023

Document the size, consistency and location in the notes to compare if they represent. Royal Children’s Hospital. Royal Children’s Hospital, Melbourne. They may grow again with subsequent upper respiratory tract infections. DOI 10.1016/j.cpha.2017.12.003 2017.12.003 Machado De Carvalho G, Silva de Lavor M et al.

Pediatrics 124

Pediatrics Documentation/Coding Emergency Department Ultrasounds 124

Pediatric EM Morsels

AUGUST 18, 2023

None of the patients were documented to have joint disease at follow up. Etminan 2019) In Belgium between 2010 – 2013, of the 262 children treated with fluroquinolones while hospitalized, only 17% were used for labelled indications. There were 2523 children included. 451 pediatric patients were included. J Pediatric Infect Dis Soc.

Pediatrics 130

Pediatrics Infectious Diseases Seizures Hospitals 130

ACEP Now

JULY 7, 2024

My current practice is a hybrid of academic and community sites, and I have worked in myriad community hospitals from busy ones to single coverage critical access hospitals. If you have a difficult outcome, it is helpful to know what risk management support you have at your hospital. Each has its own challenges and lessons.

Resuscitation 98

Resuscitation Risk Management Hospitals Critical Access 98

RebelEM

JULY 3, 2023

What They Did: Researchers conducted a multicenter, retrospective cohort study in three community hospitals and two freestanding emergency departments. The study was dependent on EMR documentation which is prone to error. Critical information such as HR, SBP, drug administration times were occasionally missing.

Administration 98

Administration Outcomes Documentation/Coding Emergency Department 98

RebelEM

JUNE 8, 2023

The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients. Emergency department hypotension predicts sudden unexpected in-hospital mortality: a prospective cohort study. PMID: 31270748 Maheshwari K, et al. Intensive Care Med. 2018;44(6):857–67. PMID: 29872882 Jones AE, et al. 2006;130(4):941–6.

Administration 98

Administration Emergency Department Outcomes Documentation/Coding 98