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. Prior to ChatGPT, clinicians did not operate in an information resource vacuum, as is frequently the case in these contrived situations.

Documentation/Coding 95

Documentation/Coding Operations Emergency Department Wellness 95

American Medical Compliance

FEBRUARY 9, 2024

Monitoring and Auditing Compliance officers regularly monitor the organization’s operations to identify potential compliance issues. Compliance officers maintain detailed records of compliance activities, investigations, and corrective actions.

Operations 78

Operations Best Practices Patient Safety Documentation/Coding 78

AED Leader

JUNE 25, 2024

Keep Track of Maintenance and Servicing Proper documentation of maintenance and servicing activities is crucial for record-keeping and compliance purposes. Train Staff in AED Operation and Maintenance Proper training is essential for effectively using and maintaining your Philips AED.

Operations 52

Operations Best Practices Documentation/Coding Shock 52

The Trauma Pro

JULY 19, 2024

As you know, one other mandatory committee is required of all trauma centers, the Trauma Operations Committee (Ops). In this post, I will: describe how often your operations committee should meet help you determine whether your two committees should meet on the same day or separately How Often? Is it the same as your PI committee?

Operations 147

Operations Documentation/Coding Administration 147

ACEP Now

NOVEMBER 14, 2023

In 1901, UVA opened its first hospital with 25 beds and three operating rooms. The emergency department (ED) at UVA was rebuilt in 2019 and the department had not fully optimized its operations when COVID-19 hit. They also developed standard work documents for each role.

Academics 52

Academics Emergency Department Leadership Operations 52

American Medical Compliance

SEPTEMBER 10, 2023

The patient must be competent to decide voluntarily whether to undergo the operation or intervention. According to the Joint Commission, all aspects of informed consent must be documented “in a form, progress notes, or elsewhere in the record.” What Documents are Required to Obtain a Patient’s Consent?

Blood Transfusions 52

Blood Transfusions Documentation/Coding Operations 52

ACEP Now

JUNE 14, 2024

Two years ago, an ACEP Now article covered the issue of transfer challenges resulting from early pandemic operations. 1 As fresh challenges of the pandemic and hospital operations changed emergency medicine practice, one of the more challenging areas was the movement of admitted patients out of the first emergency department (ED).

Emergency Department 52

Emergency Department Hospitals Operations Leadership 52

AED Leader

JUNE 11, 2024

When faced with a life-threatening situation, every second counts, and having a defibrillator that is easy to operate can make a significant difference. Philips defibrillators are equipped with long-lasting batteries that provide extended operational life. How often should the batteries be replaced in Philips defibrillators?

CPR 52

CPR Shock Resuscitation Operations 52

PulmCCM

FEBRUARY 5, 2024

You can read the document here. Read the original document here. Recall the panel also recommended abdominal CT earlier in the guideline for postoperative patients, and acknowledges CT might be the better first test (rather than ultrasound) in at least some post-op and non-operative critically ill patients. What’s a Fever?

Best Practices 111

Best Practices Ultrasounds Infectious Diseases Sepsis 111

AED Leader

JULY 3, 2024

This durability is essential, particularly for businesses operating in demanding or outdoor environments. It is recommended that you consult the product documentation or contact Cardiac Science directly for detailed warranty information. Yes, Cardiac Science provides a warranty on its AED defibrillators.

CPR 52

CPR Resuscitation Pediatrics Operations 52

Total Medical ComplianceHIPAA

JANUARY 12, 2023

During those two years, the OCR oversees all compliance activities and requires that all HIPAA related documentation and issues be submitted and approved or reported to them according to strict guidelines. Many comments to the NPRM noted that this would be an operational and compliance risk issue for providers.

Operations 104

Operations Best Practices Documentation/Coding Administration 104

ACEP Now

MARCH 13, 2024

Consequences of this are well documented and include delayed treatment, exposure to error, increased length of stay, and increased mortality. Conclusion/Recommendation ED crowding is a national patient safety issue driven by hospitals routinely operating over capacity. ED crowding impairs this mission. Click to enlarge.

Ethical Issues 52

Ethical Issues Emergency Department Operations Hospitals 52

Total Medical ComplianceHIPAA

NOVEMBER 29, 2021

Documentation or other confirmation of vaccination, however, must be kept confidential and stored separately from the employee’s personnel files under Title I of the Americans with Disabilities Act (ADA).

Documentation/Coding 52

Documentation/Coding Operations 52

ACEP Now

JUNE 7, 2023

ED leaders worked to develop new physician documentation and coding guidelines that needed to be implemented at the beginning of 2023. Software attacks crippled operations in large hospital chains, and physical assaults on ED staff continued unabated. Executive Summary of ED Operations in 2022 Volume was up from 2021.

Emergency Department 52

Emergency Department Documentation/Coding Operations EMS 52

Mind The Bleep

MAY 1, 2024

Appropriate first line management will help protect and resuscitate the soft tissues and keep the fracture still either to allow healing or until definitive management (operative fixation) is possible. The soft tissues are also damaged. Reduce, Hold, Rehabilitate Reduce The aim is to restore anatomical alignment.

Fractures 52

Fractures Documentation/Coding Head Injuries Dislocations 52

Don't Forget the Bubbles

JUNE 19, 2024

Children in the validation cohort were admitted to the intensive care unit or operating room less frequently than those in the derivation cohort. A proportion of the patients who were initially missed using the CDR were found to actually have risk factors documented in EMS reports or the medical record.

CPR 121

CPR Research Outcomes Documentation/Coding 121

Total Medical ComplianceHIPAA

NOVEMBER 29, 2021

Documentation or other confirmation of vaccination, however, must be kept confidential and stored separately from the employee’s personnel files under Title I of the Americans with Disabilities Act (ADA).

Documentation/Coding 40

Documentation/Coding Operations 40

ACEP Now

JULY 8, 2024

In this case, the LLM lacks specific domain training on the CTAS score, and the predictions do not have the appropriate foundational training to operate accurately. As a mechanism for augmenting clinical operations, this approach may show value in passively collecting and feeding information into other systems.

Emergency Department 52

Emergency Department Operations Documentation/Coding Research 52

Advanced Medical Reviews

FEBRUARY 13, 2019

Physicians who reported marginal time for documentation were 2.8 Many physicians often have too little time for documentation, utilize non-intuitive EHR user interfaces and have either not enough or too much data. Clinical information and documentation are all streamlined through our web interface.

Documentation/Coding 64

Documentation/Coding Administration Operations Research 64

Medical Law

DECEMBER 28, 2023

In California, you are allowed to operate a dashcam while driving along public roads, as there is no expectation of privacy. Dashcams continue to grow in popularity as the technology improves and prices lower. They are now a standard feature in many new vehicles. Dashcam laws vary from state to state.

Legal Issues 52

Legal Issues Documentation/Coding Operations 52

ACEP Now

NOVEMBER 7, 2023

3 These regulations have led to widespread practices of EHI, such as test results and clinical documentation, being shared with patients in real time. Training opportunities for documentation best practices should be employed. 2 Information blocking is any practice that is “likely to interfere with access, exchange, or use of [EHI].”

Documentation/Coding 52

Documentation/Coding Best Practices Ethical Issues Academics 52

American Medical Compliance

MARCH 15, 2024

While EHRs offer numerous benefits, including improved documentation and care coordination, they also introduce complexities and potential vulnerabilities. Potential Vulnerabilities of EHRs Moreover, the proliferation of electronic health records (EHRs) presents both opportunities and challenges for FWA compliance.

Best Practices 97

Best Practices Risk Management Documentation/Coding Operations 97

The Skeptics' Guide to EM

MAY 11, 2019

Background: The first documented appendectomy was done by Claudius Amyand in 1735. This is an example of why things in evidence-based medicine can be “complicated” ( SGEM#115 and SGEM#180 Clinical Question: Operative treatment or non-operative treatment of acute Grade 1 (uncomplicated) appendicitis? Reference: Sceats et al.

Documentation/Coding 52

Documentation/Coding Operations Academics Ultrasounds 52

Medical Law

FEBRUARY 13, 2023

AB 1909 alters laws regarding e-bikes and where they are allowed to operate. Peace officers will also be required to document the reason for all traffic stops. AB 2773 requires peace officers to inform drivers why they are being pulled over. AB 2147 limits the circumstances when a pedestrian can be stopped for jaywalking.

Documentation/Coding 52

Documentation/Coding Operations 52

ACEP Now

MARCH 14, 2024

In our case, the patient had a CT of the head, cervical spine, and chest, abdomen, and pelvis with intravenous contrast demonstrated a C2, C7 compression fracture with significant bowel edema (Figure 4), and was taken to the operating room for left arm disarticulation, left below knee amputation and right above knee amputation. Am J Cardiol.

Burns 52

Burns Fluid Resuscitation EKG/ECG EMS 52

Mind The Bleep

MARCH 22, 2023

Antibiotics Obtain IV access and give prophylactic IV antibiotics as soon as possible, ideally within 1 hour of injury The type of antibiotic depends on local hospital/trust protocol Tetanus prophylaxis should also be provided Pre-Reduction Examination Assess neurological and vascular status at repeated intervals A PR or PV exam is mandatory in assessing (..)

Fractures 59

Fractures Documentation/Coding Operations Hospitals 59

The Skeptics' Guide to EM

NOVEMBER 21, 2020

The American College of Emergency Physicians ( ACEP ) has a number of documents discussing APPs in the ED. Clinical Question: How does the productivity of advanced practice providers compare to emergency physicians and what is its impact on emergency department operations? Reference: Pines et al. AEM November 2020.

Emergency Department 52

Emergency Department Telemedicine Academics Outcomes 52

PHEM Cast

DECEMBER 12, 2016

pdf Equipment required for resuscitative thoracotomy: Surface anatomy: Appearance of pericardial clot A foley catheter being used to fill a cardiac wound – note how easily this could be pulled out.

Military 52

Military Resuscitation Emergency Department Documentation/Coding 52

The Skeptics' Guide to EM

JANUARY 23, 2021

That SGEMHOP episode asked how the productivity of APPs compare to emergency physicians and what is its impact on ED operations? The American College of Emergency Physicians ( ACEP ) also has a number of documents discussing APPs in the ED. Background: We covered the use of advanced practice providers (APPs) on the SGEM#308.

Research 52

Research Poisoning Documentation/Coding Outcomes 52

ACEP Now

JUNE 6, 2023

A medical student reports a murmur, not documented by either the emergency physician or the cardiologist. POCUS: Point-of-care ultrasound for AD is highly specific, but operator-dependent, and lacking in sensitivity—although late–model units can have sensitivity as high as 80-85 percent. Then what? He denies back pain.

EKG/ECG 85

EKG/ECG Stroke Documentation/Coding Operations 85

Taming the SRU

SEPTEMBER 1, 2023

to divert the plane).

Sepsis 88

Sepsis Administration Documentation/Coding Fractures 88

Resus Review

SEPTEMBER 28, 2015

Inappropriate delay of establishing a surgical definitive airway with a cricothyrotomy has been documented in field and hospital operations 1,2. J Spec Oper Med. This can be attributed to many factors including: Failure to recognize Can’t Intubate-Can’t Ventilate scenario. Selected Readings Mabry RL, Frankfurt A.

Operations 52

Operations Documentation/Coding Hospitals 52

Don't Forget the Bubbles

MARCH 11, 2024

Craniosynostosis needs urgent referral and is usually corrected operatively before a child’s first birthday. Recommendations for sudden infant death syndrome prevention: a discussion document. Craniosynostosis can lead to raised intracranial pressure and failure to thrive. and can worsen and become harder to correct over time.

Radiology 59

Radiology Radiology Pediatrics Documentation/Coding 59

Medagadget

MAY 23, 2023

These multimodal data and rules are necessary to provide a precise diagnostic, which considers all the biological operating processes, grades, and types of rejection. It requires the integration of data from a kidney transplant biopsy ( i.e. , histological lesions scores), as well as clinical, immunological, and transcriptomic data.

Research 83

Research Hospitals Documentation/Coding Operations 83

Ziqitza HealthCare Ltd

JUNE 18, 2023

By automating these processes, healthcare providers can improve efficiency, reduce errors, and lower operational costs. NLP algorithms can transcribe and analyze voice recordings, enabling real-time documentation of patient information, symptoms, and interventions.

Documentation/Coding 52

Documentation/Coding Administration Ambulance Services Outcomes 52

Resus Review

FEBRUARY 12, 2015

The patient is positioned and prepped in the same way as for the standard operative tracheostomy. Elimination of scheduling difficulty associated with operating room and anesthesiology teams for critical care patients. Dont forget to document your perc trach procedure well. Only then should the endotracheal tube be removed.

Operations 52

Operations Documentation/Coding Ultrasounds Wellness 52

RebelEM

MARCH 9, 2023

Document at each reassessment and always have a low threshold to add on a CTH or labs if the patient is not progressing appropriately. As always, document clinical sobriety before discharge. Operational criteria for the classification of chronic alcoholics: identification of Wernicke’s encephalopathy. Alcohol Alcohol.

Psychiatric 52

Psychiatric Emergency Department Documentation/Coding Fractures 52