EMDocs

JULY 25, 2024

The brother’s wife calls the airport police who are able to locate him and send him to a nearby hospital. 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.

Documentation/Coding 94

Documentation/Coding Hospitals Patient Safety Emergency Department 94

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. Well-meaning providers who are not highly fluent may contribute to miscommunication and diagnostic errors.

Documentation/Coding 94

Documentation/Coding Emergency Department Federal Emergency Management Agency Best Practices 94

Dr. Smith's ECG Blog

MARCH 14, 2024

The most recent study found a NPV of 100% of triage ECGs labeled ‘normal’ or ‘otherwise normal’ for final hospital diagnosis of ACS, and concluded that avoiding physician interruption would “alleviate interruptions in workflow and improve patient safety.” It is well known that NOMI usually has a normal ECG or nonspecific ECG.

EKG/ECG 122

EKG/ECG Documentation/Coding Patient Safety Outcomes 122

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. Well, that can be a problem. Sometimes things we do are well grounded in evidence. They sit in a Google document.

Documentation/Coding 98

Documentation/Coding Wellness EKG/ECG Hospitals 98

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. 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. And we probably won’t, ever.

Fractures 124

Fractures Documentation/Coding Hospitals Research 124

Mind The Bleep

FEBRUARY 2, 2025

However, as an F1, you may well know the patient best and therefore you may be best placed to refer the patient. Hospital/NHS number is 1234. She is otherwise in good health and is responding well to chemotherapy. Ronan is a 12yr old boy who has a suspected diagnosis of leukaemia.

Radiology 96

Radiology Radiology Sepsis Documentation/Coding 96

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

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

Mind The Bleep

FEBRUARY 2, 2025

In some hospitals, there is an infection ward round and MDTs for selected patients, however elsewhere your phone call may be all the information micro receive about the patient whose samples they are processing. Also, in larger hospitals, virology may be a separate department with its own advice system.

Radiology 98

Radiology Radiology Documentation/Coding Hospitals 98

ACEP Now

OCTOBER 10, 2024

He completed residency in emergency medicine through Emory while training at Grady Hospital in Atlanta. Most recently, Dr. McCormick served as an emergency physician at Northside Hospital. In the Atlanta region, we had AMC, one of the largest hospitals in the region closed. Overburden the other hospital systems.

Telemedicine 105

Telemedicine Critical Access Hospitals Administration 105

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. You are well prepared for this. Lead your room well. If the resuscitation does not go as well as you wanted, learn from it and move on.

Resuscitation 98

Resuscitation Risk Management Critical Access Hospitals 98

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.

Fluid Resuscitation 98

Fluid Resuscitation Documentation/Coding Resuscitation EMS 98

RebelEM

JUNE 22, 2023

Population: Adults aged 30-85 years of age with BMI > 25 ( > 23 in those identifying as Asian or Latino) who had COVID-19 symptoms for fewer than 7 days and a documented SARS-CoV-2 positive PCR or antigen test within 3 days of enrollment without prior SARS-CoV-2 infection. Pregnant/lactating patients were not excluded.

Outcomes 135

Outcomes Research Documentation/Coding Wellness 135

Sensible Medicine

MAY 15, 2024

At the same time, I struggle to see how such a person could run codes and work in trauma surgery. In this week’s Sensible Medicine podcast, I asked why students have an entire lecture with prolonged discussion of whether a patient coming to the hospital from prison should be called a prisoner. What happens when you walk and talk?

Administration 111

Administration Documentation/Coding Hospitals Wellness 111

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. 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

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

Sensible Medicine

APRIL 12, 2024

For probably the twelfth time on Sensible Medicine, I’ll reference Lisa Rosenbaum’s essay, Being Well while Doing Well — Distinguishing Necessary from Unnecessary Discomfort in Training which brought some of the current inter-generational angst to the fore. That 95-hour work week was not all work.

Radiology 80

Radiology Radiology Hospitals Documentation/Coding 80

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 90

Stroke Administration Documentation/Coding Outcomes 90

Sensible Medicine

JUNE 30, 2023

Patients present with troublesome symptoms that they “just want checked out before the weekend” and I’m left either worrying about them all weekend or admitting them to the hospital where I know little will happen for the next two days. She did not require hospitalization. It was not exertional.

Hospitals 98

Hospitals Hospice Resuscitation COPD 98

Sensible Medicine

SEPTEMBER 26, 2023

As background, a 2018 article in Health Affairs tried to look at the issue of how to best communicate with patients after a problem or adverse event; the paper studied what happened before and after a new communications program was implemented at 4 Massachusetts hospitals. A key question is how the hospital should react afterwards.

Research 121

Research Hospitals Documentation/Coding Outcomes 121

RebelEM

AUGUST 22, 2024

1,2 Intra-arterial (IA) tPA has also shown benefit but is less well studied. Finally, most hospitals lack the necessary protocols and processes to coordinate the complex interdisciplinary care patients with RAO may require. Patients whose last known well (LKW) time was within 24 hours of presentation. 1 week after treatment.

Stroke 85

Stroke Administration Outcomes Documentation/Coding 85

Sensible Medicine

AUGUST 21, 2023

Administrative data sets are often collected for the purpose of billing, or costing, or administrative organization, and thus are extremely vulnerable to up coding or intentional or accidental omissions. Next week I am going to show you what a well-done medical study looks like. It is our goal. Thanks for your support.

Administration 98

Administration Outcomes Research COPD 98

ACEP Now

SEPTEMBER 5, 2024

With elimination of CME funding in many of our hospitals and groups, it is crucial to continue to add value and communicate that value to residents before graduation. While some issues are handled locally, many issues cannot be solved in our emergency department or hospital. If ACEP is already doing this, why be a member?

Leadership 98

Leadership PPE EMS Wellness 98

Don't Forget the Bubbles

JUNE 19, 2024

Well-designed multicentre large studies in children were warranted; cue Leonard et al. This may limit the generalisability of the results in regional/community hospital settings. 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 124

CPR Research Outcomes Documentation/Coding 124

Downeast Emergency Medicine

DECEMBER 1, 2021

329 participants were enrolled at an urban teaching hospital over a period of four years. Rosenberg and colleagues took a qualitative approach when investigating barriers and facilitators to successful implementation of ED-initiated buprenorphine programs in critical access hospital EDs across Maine.

Emergency Department 52

Emergency Department Documentation/Coding Leadership Administration 52

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. Ultrasound is well-suited for identifying most serious biliary system abnormalities.

Best Practices 111

Best Practices Ultrasounds Infectious Diseases Sepsis 111

ACEP Now

JUNE 7, 2023

Whereas previous versions of GPT were unable to pass the medical examinations, GPT-4 demonstrated scores of approximately 85 percent correct on each Step of USMLE, well above the passing threshold. Future versions are likely to have greater accuracy and error-checking abilities, as well as improved domain-specific generative abilities.

Documentation/Coding 78

Documentation/Coding Wellness Administration Research 78

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 86

Emergency Department Hospitals Documentation/Coding Wellness 86

Dr. Smith's ECG Blog

MAY 26, 2023

Thus, since high dose insulin's (HDI) primary beneficial effect on calcium channel overdose is to as a positive inotrope, it does not work well for dihydropyridine overdose. A NSWER : In Figure-3 — I have color-coded P waves in the long lead II rhythm strip of ECG #2. How Are the P Waves Color-Coded? Learning Points: 1.

Shock 98

Shock EKG/ECG Documentation/Coding Resuscitation 98

Taming the SRU

SEPTEMBER 1, 2023

Lane & Mcdonough Definition of an immediate whole body CT (iWBCT) scan Shortly after patient arrival.

Sepsis 95

Sepsis Fractures Documentation/Coding Administration 95

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 97

Administration Emergency Department Outcomes Documentation/Coding 97

Don't Forget the Bubbles

JULY 26, 2023

A cardiac family history should of course be sought, but think a little outside the box as well. This has been trialled (out of hospital) in known children with SVT. On arrival at hospital the child was well with normal observations. Family history. The episode was reported to last around a minute.

EKG/ECG 98

EKG/ECG Hospitals Shock Documentation/Coding 98

SheMD

MAY 11, 2023

Transcripts were coded to sort data into “leadership occurrences” or “unrelated to leadership” as well as critical treatment decisions. CPR-related performance items were coded by the second as present or absent. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians.

Leadership 52

Leadership Documentation/Coding Teamwork CPR 52

Mind The Bleep

JANUARY 28, 2025

First Aid Measures : Document if any initial care has been done, such as cleaning or dressing the wound. Documentation Clearly record findings, including measurements and descriptions of the wound, and consider photographic documentation if appropriate. British journal of hospital medicine (London, England : 2005), 83(12), 17.

Documentation/Coding 52

Documentation/Coding Head Injuries Fractures Emergency Department 52

American Medical Compliance

JANUARY 25, 2024

The CDC’s FluSurv-NET system, a sentinel network of healthcare facilities, documented over 104,000 flu-related hospitalizations across 13 states during past flu seasons. The year 2024 marks another significant chapter in the healthcare industry’s ongoing battle against infectious diseases, and the numbers speak volumes.

Infectious Diseases 111

Infectious Diseases PPE CDC Documentation/Coding 111

The Skeptics' Guide to EM

MAY 11, 2019

Background: The first documented appendectomy was done by Claudius Amyand in 1735. J AMA Surgery 2018 * Population: Adult patients admitted to hospital with a diagnosis of acute uncomplicated (Grade I) appendicitis. Case: An 18-year-old woman presents with a Grade 1 appendicitis (Tominaga et al J Trauma Acute Care Surg 2016).

Documentation/Coding 40

Documentation/Coding Operations Academics Ultrasounds 40