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

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 105

Documentation/Coding Leadership Best Practices Outcomes 105

Mind The Bleep

FEBRUARY 2, 2025

The longer these negative interactions go on, the more likely they are to significantly impact on outcomes for our patients, our colleagues and ourselves. If its a No, then cut your losses, document your interaction, speak to colleagues and take care with this individual in future. It is hard to speak up sometimes. Level 2: Alert.

Documentation/Coding 98

Documentation/Coding Outcomes Burns Wellness 98

Dr. Smith's ECG Blog

MARCH 10, 2025

They concluded, "Our findings increase confidence in the normal automated GE Marquette 12 SL ECG software interpretation to predict a benign outcome. Smith comment: this is a very stupid outcome measure) What if we use that methodology for the ECG above? What is the gold standard for ECG interpretation: patient outcome!!!

EKG/ECG 89

EKG/ECG Outcomes Documentation/Coding Emergency Department 89

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 129

Documentation/Coding Pediatrics Research Outcomes 129

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

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. What was the outcome? The outcome was not illness. The control group was explicitly instructed not to wear masks.

Documentation/Coding 144

Documentation/Coding Outcomes Research 144

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 114

Dislocations Fractures Soft Tissue Injuries Outcomes 114

ACEP Now

NOVEMBER 7, 2024

Wound management in the ED is only a starting point, and appropriate referral and follow-up are key to an improved outcome. Photographic documentation of the wound is helpful to enhance continuity of care. Additionally, lower leg edema invokes consideration for applying compression dressings or stockings. Back to the patient.

Burns 97

Burns Documentation/Coding Outcomes Emergency Department 97

ACEP Now

OCTOBER 29, 2024

Our nurse did not study Paul Ekman’s Facial Action Coding System for Action Units to code “fear” in the patient’s face. 4 However, emergency physicians rely on gestalt to predict outcomes well. Actively, I ask them on their patients that we both had the opportunity to see: What abscesses would they prefer to pack?

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

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

RebelEM

JUNE 29, 2023

Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study. The CT FIRST Trial: Should We Pan-CT After ROSC?, REBEL EM Blog, June 1, 2023. Available at: HERE Branch KHR et al. Resus 2023.

CPR 145

CPR EMS Documentation/Coding Outcomes 145

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. The current analysis showed that EVT was superior in functional outcomes across a variety of ischemic severities and penumbra profiles on imaging.

Documentation/Coding 98

Documentation/Coding Stroke Emergency Department Pediatrics 98

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 90

Documentation/Coding Pediatrics Research Outcomes 90

Dr. Smith's ECG Blog

MARCH 14, 2024

Written by Jesse McLaren Three patients presented with acute chest pain and ECGs that were labeled by the computer as completely normal, and which was confirmed by the final cardiology interpretation (which is blinded to patient outcome) also as completely normal. The reliability of these ECGs should be based on patient outcome.

EKG/ECG 119

EKG/ECG Documentation/Coding Patient Safety Outcomes 119

Dr. Smith's ECG Blog

JUNE 7, 2024

What was the outcome and final diagnosis? 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 112

EKG/ECG Documentation/Coding EMS Outcomes 112

The Trauma Pro

MAY 3, 2024

They separated all patients with acetabular and pelvic ring fractures using ICD-10 codes. Various hospital outcomes were tabulated, including hospital charges, mortality, and discharge location. AE and PPP have equivalent outcomes. You can feel comfortable that outcomes will be the same as AE.

Fractures 113

Fractures Radiology Radiology Documentation/Coding 113

Emergency Medicine Journal

DECEMBER 30, 2024

Background Calls to emergency departments (EDs) from ambulances to alert them to a critical case being transported to that facility that requires a special response (‘pre-alerts’) have been shown to improve outcomes for patients requiring immediate time-critical treatment (eg, stroke).

Emergency Department 52

Emergency Department Stroke Documentation/Coding Outcomes 52

PulmCCM

SEPTEMBER 17, 2023

The Centers for Disease Control and Prevention formally called on hospitals to develop robust sepsis care programs to systematically identify and treat sepsis, track outcomes, and improve care delivery.

CDC 98

CDC Sepsis Hospitals Documentation/Coding 98

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 105

Documentation/Coding Best Practices Operations Outcomes 105

PulmCCM

JANUARY 15, 2025

Draft Guidance Document Wong et al. Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19. Analysis of Discrepancies Between Pulse Oximetry and Arterial Oxygen Saturation Measurements by Race and Ethnicity and Association With Organ Dysfunction and Mortality.

Academics 81

Academics Documentation/Coding Administration Research 81

EMDocs

AUGUST 22, 2024

13 Interventions may include: Ascertaining a patient’s preferred language early in the clinical encounter (during registration, for instance), and clearly documenting this preference in a place that is visible to all providers. Utilizing certified interpreters and documenting their use. Educating patients on their rights.

Documentation/Coding 104

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

Pediatric EM Morsels

JULY 28, 2023

A critical MORSEL is that every child you treat for DKA needs to have an initial thorough neuro exam including cranial nerves and then frequent neuro reassessments … and document it ( so your colleagues who take over care for the kid can know if there has been a change )! Is your patient hyperglycemic, acidotic, with ketonuria?

Fluid Resuscitation 246

Fluid Resuscitation Pediatrics Resuscitation Research 246

Dr. Smith's ECG Blog

OCTOBER 18, 2023

1-3] But these studies were very short duration and used cardiology interpretation of ECGs or emergent angiography rather than patient outcomes. 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]

EKG/ECG 119

EKG/ECG Documentation/Coding Emergency Department Outcomes 119

EMDocs

MAY 9, 2024

Exam documents that he is alert and oriented but “tired appearing” and “not appearing post-ictal.” Defense : The EP did address the seizure when he documented “not post-ictal.” There is no negligence, as the documentation supports reasonable judgment. The triage nurse records the event as a “seizure” lasting 7 minutes.

Seizures 104

Seizures Dehydration Documentation/Coding Infectious Diseases 104

PulmCCM

JANUARY 6, 2025

A cluster randomized trial using all-cause mortality as an outcome was always needed to determine whether EMR alerts improve outcomes for suspected severe infection. This led the authors to speculate that qSOFA parameters were being documented more diligently on the wards randomized to screening.

Sepsis 45

Sepsis Documentation/Coding Hospitals Outcomes 45

The Skeptics' Guide to EM

AUGUST 10, 2024

A code stroke is activated, and a CT head shows a left basal ganglia hemorrhage with no vascular lesions on CT angiography. INTERACT-2 demonstrated that in patients with ICH, intensive lowering of blood pressure did not result in a significant reduction in the rate of the primary outcome of death or severe disability (SGEM#73).

Stroke 89

Stroke Airway Management Documentation/Coding Outcomes 89

The Skeptics' Guide to EM

JULY 27, 2024

It is a medical emergency that requires prompt recognition and treatment to improve patient outcomes. The primary outcome reported was no statistical difference in mortality at 28 days (8% in both groups) despite giving antibiotics 96 minutes earlier [2].

Sepsis 98

Sepsis Outcomes Documentation/Coding Hospitals 98

EMDocs

SEPTEMBER 26, 2024

This story, while unlikely to reflect the standards of most readers, has a somewhat surprising outcome. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. It wasn’t, so you weren’t called, nor did the doc need to document anything.

Radiology 97

Radiology Radiology EKG/ECG Documentation/Coding 97

EMDocs

JUNE 8, 2023

and 9 hours after onset of symptoms, with non-infarcted brain tissue, does the administration of alteplase improve functional outcome at 90 days? Subsequently reduced enrollment to 310 patients because no patients had been lost to follow-up or had insufficient data documented. Intervention: Alteplase 0.9 in alteplase group versus 0.9%

Stroke 98

Stroke Administration Documentation/Coding Outcomes 98

Don't Forget the Bubbles

MAY 31, 2023

What outcomes did they look at? Was the outcome accurately measured to minimise bias? The inability to test for SARS-CoV-2 antibodies may have led to an underestimation of the impact of the virus on the reported outcomes. All ED visits that met the criteria for ‘new onset diabetes’ or DKA (‘decompensation’) were included.

Emergency Department 135

Emergency Department Research Documentation/Coding Outcomes 135

The Trauma Pro

MAY 9, 2023

” This concept served as the basis of the [poorly documented] “Golden Hour” and for decades has directed our efforts at getting patients to a center with an immediately available OR as quickly as possible. The Pennsylvania Trauma Outcomes Study database contains a huge amount of data.

Head Injuries 130

Head Injuries Operations Documentation/Coding Outcomes 130

American Medical Compliance

APRIL 16, 2024

Our Continuing Medical Education (CME) program is committed to enhancing the knowledge, skills, and professional performance of healthcare providers to improve healthcare outcomes. Furthermore, advance directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your wishes.

Documentation/Coding 100

Documentation/Coding Research Outcomes 100

ACEP Now

OCTOBER 3, 2023

This document is an update of guidelines first published in 2000, and then updated in 2007. These guidelines present the best available evidence to support clinical decision making in the prehospital setting when TBI care may have the most significant impact on outcomes; they also establish a research agenda for future investigations.

Fluid Resuscitation 98

Fluid Resuscitation Documentation/Coding Resuscitation EMS 98

American Medical Compliance

JUNE 28, 2024

Our Continuing Medical Education (CME) program is committed to enhancing the knowledge, skills, and professional performance of healthcare providers to improve patient care outcomes. Languages: American English Key features: Audio narration, learning activity, and post-assessment.

Teamwork 96

Teamwork Documentation/Coding Outcomes 96

RebelEM

JULY 3, 2023

Pregnant or incarcerated patients Documentation for systolic BP is incomplete Intervention: Administration of IV calcium within 60 min prior to or 30 min after IV diltiazem administration in patients with AF/AFL with RVR. Limitations: The primary and secondary outcomes were nearly all disease oriented and not patient oriented.

Administration 96

Administration Outcomes Documentation/Coding Emergency Department 96

EMDocs

OCTOBER 10, 2024

Exam is normal except for tenderness as documented in the diagram. She never had a documented abdominal exam. I just failed to document it. The EP documented seeing the patient and agreed with the ARNP’s plan. Takeaways : There are more questions than answers in this case, but: This is a common outcome.

Documentation/Coding 97

Documentation/Coding Hospitals Sepsis Infectious Diseases 97