The Trauma Pro

JUNE 28, 2024

Work not documented is work not done” This is my quote and it’s one of my favorites. Accurate, complete, timely, and legible documentation is a must! Documentation, or lack thereof, will not get you sued. Documentation, or lack thereof, will not get you sued. And providing a date and time is absolutely critical.

Documentation/Coding 202

Documentation/Coding 202

Mount Sinai EM

AUGUST 7, 2024

Evidence of right heart strain is important but the evidence of fibrinolysis during arrest is mixed with many studies showing no 30-day mortality benefit to lysing during a code. Rapidly intervened-upon cardiac tamponade in PEA during cardiac arrest has significantly higher hospital discharge rates. survival to hospital discharge rate.

Ultrasounds 235

Ultrasounds CPR Documentation/Coding COPD 235

EM Ottawa

NOVEMBER 30, 2023

Sunita Puir, a palliative care doctor, talks about how it is an “open secret in medicine that CPR is brutal and rarely effective,” yet how the public seems […] The post Decoding Code Status: A Goals of Care Framework appeared first on EMOttawa Blog.

Documentation/Coding 78

Documentation/Coding CPR Resuscitation 78

American Medical Compliance

AUGUST 15, 2024

Codes of conduct serve as a foundational guide for healthcare personnel, outlining the ethical principles and professional responsibilities that govern their actions and decisions. Buy Course Today The post Code of Conduct Refresher Training appeared first on American Medical Compliance.

Documentation/Coding 62

Documentation/Coding Patient Safety 62

American Medical Compliance

JUNE 21, 2024

Here are key areas where they can make a significant impact. Accurate Documentation and Coding Accurate documentation and coding are fundamental in preventing fraud, waste, and abuse. This includes segregation of duties, regular audits, and having checks and balances in billing and coding processes.

Documentation/Coding 91

Documentation/Coding Leadership Best Practices Outcomes 91

The Trauma Pro

NOVEMBER 10, 2023

You can download the full document using the link at the bottom of this post. Document your consultation results in writing (paper or EMR) promptly. Bottom line: A uniform “code of behavior” is essential! Click here to download a sample Trauma Services consultant guidelines document.

Documentation/Coding 113

Documentation/Coding Best Practices 113

The Trauma Pro

JUNE 21, 2024

This situation was first documented in a paper published in the 1960s, which noted that VIP patients have worse outcomes. The VIP syndrome occurs in healthcare when a celebrity or other well-connected “important” person receives a level of care that the average person does not. Who is a VIP? It may be a celebrity. A family member.

Documentation/Coding 290

Documentation/Coding Outcomes Hospitals Wellness 290

Sensible Medicine

OCTOBER 19, 2023

We wrote this letter and submitted it to the journal, documenting that the trial violated ethical codes. Kids are a vulnerable population— subject to teasing and bullying— and frankly the dogs were not that good at sniffing COVID19. Lots of false positives and negatives. Yet the journal refuses to print it.

Documentation/Coding 130

Documentation/Coding Pediatrics Research Outcomes 130

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. Microvascular dysfunction — cardiac vasculitis — intravascular thrombosis.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

Emergency Live

DECEMBER 21, 2023

The Importance of Color Codes in Hospital Emergency Situations and on Rescue Vehicles Color Codes in Hospital Emergencies In hospital settings, color codes are used to communicate specific emergency situations quickly and effectively.

Documentation/Coding 105

Documentation/Coding Hospitals 105

Ken Grauer, MD

JUNE 22, 2024

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". KEY Point: The respiratory rate that is written on the chart does not count!

EKG/ECG 433

EKG/ECG Stroke Documentation/Coding Wellness 433

Pediatric EM Morsels

OCTOBER 27, 2023

He, along with Dr. Bob Luten, a PEM physician in Jacksonville, FL , designed the Broselow-Luten color-coded length-based system to help estimate a child’s weight, and thereby offload the cognitive burden of medication dosing and choice of equipment sizes in pediatric resuscitations. .”

Pediatrics 269

Pediatrics Resuscitation Documentation/Coding Wellness 269

Dr. Smith's ECG Blog

NOVEMBER 27, 2023

Written by Jesse McLaren A 45 year old presented with two weeks of recurring non-exertional chest pain, now constant for an hour. Below is old and then new ECG (old on top; new below). What do you think? Both ECGs have normal sinus rhythm, normal conduction and normal voltages.

EKG/ECG 94

EKG/ECG Documentation/Coding Wellness 94

The Trauma Pro

JULY 5, 2024

The emergency physician should be sure to convey their concerns very clearly, tell the specialist that the conversation will be documented carefully, and then do so. Be sure to fill out a consent as soon as practical, and document any attempts that were made to obtain it. Make sure all is documented well on the consent or in the EHR.

Documentation/Coding 113

Documentation/Coding Fractures Emergency Department Wellness 113

The Trauma Pro

AUGUST 15, 2023

MTP logistics include details such as who will be delivering the blood, what actually goes in each cooler, what ratios should be used, limitations imposed by the use of frozen plasma, and documentation. Documentation is critically important, both in the trauma bay and the blood bank. And there are plenty around all the time!

Documentation/Coding 130

Documentation/Coding Best Practices Resuscitation Administration 130

The Trauma Pro

SEPTEMBER 10, 2024

And there are far more papers written than actual documented cases. For this reason, I’ll focus on field amputation for the rest of this issue. In reality, these procedures are discussed much more often than performed. There is one old paper that is cited frequently which consisted of a survey from 1996!

EMS 201

EMS Documentation/Coding 201

Emergency Live

APRIL 26, 2024

It’s a special nitrogen-containing compound that pairs with adenine, cytosine, and thymine (or uracil in RNA) to form the genetic code. One of the four main building blocks of DNA and RNA is guanine. What makes guanine unique is its […] The post The Essential Role of Guanine in DNA and RNA appeared first on Emergency Live.

Documentation/Coding 98

Documentation/Coding 98

EMCrit

DECEMBER 10, 2023

Some authors on the ATS document were from Europe, and similarly some authors […] EMCrit Project by Josh Farkas. Within the past year, two major societies have released guidelines on ARDS: the ATS (American Thoracic Society) and the ESICM (European Society of Intensive Care Medicine).

Documentation/Coding 128

Documentation/Coding 128

EMDocs

JUNE 13, 2024

We just don’t document it. If we don’t use printed instructions, document our verbal instructions regarding the most common side effects of the drug(s) being prescribed. Documenting our warnings should be standard care. State regulations and codes may place that responsibility on our shoulders.

Documentation/Coding 78

Documentation/Coding Patient Safety Emergency Department Hospitals 78

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 122

EKG/ECG Documentation/Coding Emergency Department Outcomes 122

The Trauma Pro

MARCH 14, 2024

Related link: Facilities Guidelines Institute documents In this case, the FGI guidelines say nothing about the trauma team size, which is a critical factor in space planning. Use the work of others as a springboard to jump start your own efforts at solving the problem.

Resuscitation 162

Resuscitation Documentation/Coding Hospitals 162

EMDocs

APRIL 2, 2024

Check the pulse RSI= Resuscitation Sequence Intubation Hypoxia, Hypotension, and Acidosis are the reason patients code during/post intubation These patients are super high risk for all 4 Optimize first pass success – Induction agent + paralytic Unconscious patients will still have muscle tone Induction Ketamine or Etomidate at half doses (i.e.,

Documentation/Coding 93

Documentation/Coding CPR EKG/ECG Sepsis 93

PDC Healthcare

JANUARY 16, 2023

Thousands of healthcare facilities across the country have adopted standardized, color-coded alert wristbands […]. Being able to easily differentiate and identify these risks can be the difference in ensuring a patient’s safety and makes fulfilling a patient’s needs easier for healthcare workers.

Documentation/Coding 98

Documentation/Coding Patient Safety 98

PulmCCM

SEPTEMBER 17, 2023

Fully implemented, CDC’s toolkit would promote sepsis into the major leagues of “code strokes” and “code STEMIs” — highly prioritized system-wide operational programs enjoying executive sponsorship and significant financial and human resources.

CDC 98

CDC Sepsis Hospitals Documentation/Coding 98

Sensible Medicine

AUGUST 3, 2024

These participants received a gift card code in this email so they could purchase a 50-pack of masks at their local pharmacy. To reiterate, the intervention was an email with instructions and a gift code. Half of the participants were instructed to wear masks when out in public. What was the outcome? The outcome was not illness.

Documentation/Coding 132

Documentation/Coding Outcomes Research 132

RebelEM

JUNE 29, 2023

REBEL Cast Ep119: A Discussion with Scott Weingart on the CT FIRST Trial Click here for Direct Download of the Podcast Timing Is 6hrs reasonable because most pts excluded because of this Right before heading up to ICU seems good 1st couple hours after ROSC…pts are high risk for re-coding Where Not single coverage or stand-alone EDs Optimize and transfer…scans (..)

CPR 145

CPR EMS Documentation/Coding Outcomes 145

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

Documentation/Coding 112

Documentation/Coding Wellness Infectious Diseases EMS 112

Dr. Smith's ECG Blog

MARCH 14, 2024

We also studied 7 years of Code STEMI patients requiring emergent reperfusion, and found that 4% presented with an ECG labeled ‘normal’, often confirmed by the final blinded interpretation. Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.

EKG/ECG 113

EKG/ECG Documentation/Coding Patient Safety Outcomes 113

American Medical Compliance

MARCH 11, 2024

These are recordkeeping and documentation. In a survey , dental providers agree that careful and precise recordkeeping is indispensable, emphasizing the importance of documenting elements such as patient histories, examination results, diagnoses, radiographs, treatment plans, consent forms, and clinic notes.

Documentation/Coding 86

Documentation/Coding Best Practices Operations Outcomes 86

Dr. Smith's ECG Blog

JUNE 7, 2024

The discharge diagnosis was STEMI based on the STEMI positive ECG and code STEMI activation, with culprit lesion on angiography. Despite this clinical reality — all too many clinicians still fail to document the presence and relative severity of CP at the time each serial ECG is recorded.

EKG/ECG 102

EKG/ECG Documentation/Coding EMS Outcomes 102

Emergency Live

JANUARY 24, 2024

These confraternities, originating in Italy, have deep roots dating back to the Middle Ages, with the earliest historical documentation attesting to the foundation of the Misericordia of Florence […] The post The Misericordie: a history of service and solidarity appeared first on Emergency Live.

Documentation/Coding 98

Documentation/Coding 98

Sensible Medicine

AUGUST 17, 2024

Spending day and night coding. Think about the tech bro in a dirty, drafty San Francisco house, sleeping on a mattress on the floor, drinking Nespresso, and coding all day, and consider perhaps that what you are doing might not be any better… except with less upside. One day, we were having coffee, and she mused.

Documentation/Coding 109

Documentation/Coding Research Burns 109

PDC Healthcare

APRIL 2, 2024

The ISBT 128 is the “global standard for the terminology, identification, coding and labeling of medical products of human origin (including blood, cell, tissue, milk, and organ products). Every year the ISBT 128 publishes labeling standards for essential items that hospital lab professionals use, including blood bags.

Documentation/Coding 81

Documentation/Coding Hospitals Patient Safety 81

Emergency Live

JANUARY 20, 2024

One of the earliest documented female firefighters was Molly Williams, a member of Oceanus Fire Company No. The Pioneers in the Fight Against Fires in the Victorian Era The Early Flames of Change The history of women in firefighting has deep roots dating back to the early 1800s.

Documentation/Coding 98

Documentation/Coding 98

EMDocs

MAY 4, 2024

. #1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation.

Documentation/Coding 79

Documentation/Coding Stroke Emergency Department Pediatrics 79

Dr. Smith's ECG Blog

MARCH 4, 2024

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? (THE PM CARDIO OMI AI APP) If you want this bot to help you make the early diagnosis of OMI and save your patient and his/her myocardium, you can sign up to get an early beta version of the bot here.

EKG/ECG 115

EKG/ECG Documentation/Coding Wellness Resuscitation 115

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 85

Elder Abuse Emergency Department Documentation/Coding Hospitals 85