Emergency Medicine Journal

AUGUST 23, 2023

Interviews were transcribed verbatim and coded inductively by the primary researcher. We coded all items to capture experiences of 111 First within the full project coding tree and from this constructed two explanatory themes which were refined by the wider research team.

Emergency Department 75

Emergency Department Urgent Care Documentation/Coding Patient Safety 75

American Medical Compliance

OCTOBER 25, 2024

What’s more, they improve operational efficiency and enhance patient trust. It could target several key areas, such as patient privacy and security to ensure compliance with HIPAA guidelines, or billing and coding accuracy to prevent fraud and abuse under CMS regulations. What are you aiming to achieve with the audit?

Documentation/Coding 85

Documentation/Coding Operations Best Practices Shock 85

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

Dr. Smith's ECG Blog

JUNE 13, 2024

Her first set of vitals were documented: BP 116/57 Pulse 94bpm Respiratory rate 24/min O2 sat 90% on room air Temp 97F She had been cleaning a Jeep in the sun, and was sunburned. The physician documented “normal sinus rhythm”. The physician documented that she was “improved” and the patient was discharged. CK MB was 1.9

EKG/ECG 94

EKG/ECG Documentation/Coding EMS Burns 94

American Medical Compliance

NOVEMBER 8, 2024

Proper injury reporting protects patients, supports a safe workplace, and shields healthcare providers from potential legal issues that may arise due to negligence or lack of documentation. Non-compliance can result in hefty fines, inspections, and audits that disrupt operations.

Documentation/Coding 85

Documentation/Coding Legal Issues Operations Incident Reporting 85

American Medical Compliance

OCTOBER 3, 2024

Dental practices must maintain radiation safety protocols and provide radiation safety training for staff operating radiographic equipment. 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 95

PPE Hazardous Materials Documentation/Coding Operations 95

American Medical Compliance

FEBRUARY 17, 2024

With the Occupational Safety and Health Administration (OSHA) setting standards to protect workers from occupational hazards, healthcare organizations face unique challenges in maintaining compliance due to the complexity of their operations and the diverse array of risks inherent in patient care.

Best Practices 89

Best Practices PPE Infectious Diseases Documentation/Coding 89

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

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 86

Documentation/Coding Operations Emergency Department Wellness 86

PulmCCM

JUNE 5, 2023

Check out the preliminary program , and use code PULMCCM15 to get 15% off the attendance fees. Most health systems haven’t done the operations work (including paying for people and technology) to build robust screening programs, and physicians haven’t been pushing hard for it either. Rochelle Walensky steps down this month.

Advances Cardiac Life Support (ACLS) 96

Advances Cardiac Life Support (ACLS) Documentation/Coding CPR Shock 96

EB Medicine

NOVEMBER 1, 2021

Also, this month use code ACEP21! It is in Beta and your feedback is welcome. ,* Also, this month use code ACEP21! EMplify – November 2021 Announcements: The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. Coming to Google Play soon.

Fractures 52

Fractures Documentation/Coding Operations Emergency Department 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

American Medical Compliance

APRIL 17, 2024

Life Safety Code & Health Care Facilities Code Requirements Moreover, the life safety code (LSC) is a set of fire protection requirements that provide a reasonable degree of safety from fire. It covers construction, protection, and operational features designed to provide safety from fire, smoke, and panic.

Documentation/Coding 52

Documentation/Coding Best Practices Operations Outcomes 52

Mind The Bleep

OCTOBER 22, 2024

Behind the scenes, this entry is assigned a clinical code (such as a SNOMED CT code) so it can be recognised as a blood pressure value by any health record software worldwide if the record should ever be exported there. Some clinicians might have an interest in coding and software development (also known as clinicians who code ).

Documentation/Coding 59

Documentation/Coding Telemedicine Urgent Care Operations 59

Don't Forget the Bubbles

MAY 10, 2023

Then you hear the words coming out of the speaker, “ Paediatric code black. Paediatric code black ”. You’ve heard the phrase code black before – it’s a traumatic cardiac arrest. You know a paediatric code black means paediatric traumatic cardiac arrest. Then the patient is rapidly moved to the operating theatre.

Emergency Department 91

Emergency Department Resuscitation Documentation/Coding Teamwork 91

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 40

Documentation/Coding Operations Academics Ultrasounds 40

Taming the SRU

SEPTEMBER 1, 2023

to divert the plane).

Sepsis 95

Sepsis Documentation/Coding Fractures Administration 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 71

Operations Best Practices Patient Safety Documentation/Coding 71

American Medical Compliance

AUGUST 7, 2024

Moreover, compliance with HIPAA helps healthcare providers avoid substantial fines and legal penalties associated with data breaches, thereby maintaining compliance with federal standards and ensuring the smooth operation of their practices. It ensures healthcare providers operate ethically.

Hazardous Materials 81

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 81

RebelEM

AUGUST 22, 2024

Moreover, there are multiple operational and patient-specific barriers rendering timely thrombolytic administration difficult. Documented at the following time points: Before treatment. Time from Presentation to Treatment: The duration from when the patient arrived at the ED and the stroke code was called to the administration of tPA.

Stroke 85

Stroke Administration Outcomes Documentation/Coding 85

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

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

Taming the SRU

JULY 25, 2024

Femoral nerve block case review - morbidity & mortality - community practice - r2 Clinical pathologic case - visual diagnosis - when time matters - operational aspects of stroke care Femoral nerve Block Case Review WITH dr. stolz Why do we care about regional anesthesia, specifically femoral nerve blocks?

Stroke 97

Stroke Fractures Outcomes Operations 97

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 124

CPR Research Outcomes Documentation/Coding 124

Taming the SRU

MAY 11, 2024

Usually presents consistent with failure of that organ. For mid-shaft femur fractures, traction appears to may reduce blood loss and pulmonary complications, but the available data is very scarce.

Administration 91

Administration Resuscitation Fluid Resuscitation Research 91

RebelEM

NOVEMBER 6, 2024

Elbow Dislocation Definition: Disarticulation of the proximal radius & ulna bones from the humerus Epidemiology: Incidence Second most common joint dislocation (after shoulder) in adults Most commonly dislocated joint in children Accounts for 10-25% of all injuries to the elbow ( Cohen 1998 ) Posterolateral is the most common type of dislocation (..)

Dislocations 118

Dislocations Fractures Soft Tissue Injuries Outcomes 118

Medical Law

FEBRUARY 4, 2021

Vehicle Code Section 312.5(1)-(3)). Vehicle Code Section 312.5(c)). Vehicle Code Sections 21200 et seq ). Vehicle Code Section 21212). For example, all E-bike operators need to be 16 years or older and all Class 3 riders must wear a helmet regardless of age. Vehicle Code Section 21213).

Documentation/Coding 52

Documentation/Coding Legal Issues Operations 52

PulmCCM

MARCH 11, 2024

About 544,000 99292 codes were billed to CMS in 2021, according to ACCP , reportedly stable at about 10% of the total bills. Ascension is a $27 billion, 140-hospital conglomerate operating in 19 states—the third largest system in the U.S The other new signal is in corporate health care operations: One of the largest U.S.

Hospice 52

Hospice Documentation/Coding Administration Hospitals 52

Mind The Bleep

SEPTEMBER 14, 2024

Operative management: Surgical washout of the flexor sheath within 24 hours of the decision to operate. Non-operative management: An experienced hand surgeon should make the decision for non-operative management. Non-operative management: An experienced hand surgeon should make the decision for non-operative management.

Operations 52

Operations Sepsis Documentation/Coding 52

Total Medical ComplianceHIPAA

SEPTEMBER 19, 2024

Selecting the right IT company for a healthcare organization is critical to safeguarding data security, regulatory compliance, and optimal operational performance. IT providers should offer solutions that protect your operations in the event of an IT failure. Questions to Ask: What disaster recovery solutions do you offer?

Operations 52

Operations Documentation/Coding 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

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

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

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

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

The Skeptics' Guide to EM

JULY 30, 2022

Background: Somewhere between two and four percent of patients presenting to US EDs with abdominal pain have a small bowel obstruction (SBO) – those who are managed operatively (who are only 20-30%) account for 60,000 hospitalizations and 565,000 inpatient care days per year. Also joining us is Dr. Andrew Goldsmith.

Ultrasounds 52

Ultrasounds Operations Documentation/Coding 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