EMDocs

JULY 25, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. 0321 : During triage one of the officers informs the nurse of the patient’s detailed suicide plan. There is no documented handoff to the on-coming emergency physician (EP) who assumes care.

Documentation/Coding 104

Documentation/Coding Hospitals Patient Safety Emergency Department 104

Emergency Medicine Journal

AUGUST 23, 2023

In 2020, 111 First was introduced to triage patients before entry to the ED and to offer direct booking for patients needing ED or urgent care into same-day arrival time slots. 111 First continues to be used post pandemic, but concerns about patient safety, delays or inequities in accessing care have been voiced.

Emergency Department 75

Emergency Department Urgent Care Documentation/Coding Patient Safety 75

EMDocs

MAY 9, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. 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.”

Seizures 104

Seizures Dehydration Documentation/Coding Infectious Diseases 104

EMDocs

SEPTEMBER 26, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. The radiologist finds significant cardiomegaly and sends a report to both the ED and the patient’s PCP. 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

OCTOBER 11, 2023

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. ” The tech cleans the wound and documents it as 2cm long and “ dirty.” I thought they were incidental “ bone islands” so I didn ’ t document them. I just didn ’ t document it.

Documentation/Coding 93

Documentation/Coding Radiology Radiology Patient Safety 93

EMDocs

JUNE 28, 2023

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. EMS report includes concern for CVA, with variable documentation of face and extremity weakness. Nursing documentation includes the presence of a facial droop.

Documentation/Coding 94

Documentation/Coding EMS Stroke Patient Safety 94

American Medical Compliance

AUGUST 29, 2024

Understanding this definition helps healthcare providers recognize the importance of fall prevention as a critical aspect of patient safety. Healthcare providers must act in the best interest of their patients by promptly recognizing injuries, accurately documenting them, and reporting incidents to prevent further harm.

Patient Safety 98

Patient Safety Documentation/Coding Wellness 98

PDC Healthcare

FEBRUARY 13, 2023

Spartanburg Regional Healthcare Improves Patient Safety by Switching to Thermal Wristband and Label Printing Spartanburg Regional Healthcare System, an integrated healthcare delivery system in South Carolina, is building on its reputation for technological excellence with the recent adoption of thermal print patient identification technology.

Patient Safety 97

Patient Safety Documentation/Coding 97

PDC Healthcare

JANUARY 16, 2023

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. Thousands of healthcare facilities across the country have adopted standardized, color-coded alert wristbands […].

Documentation/Coding 98

Documentation/Coding Patient Safety 98

American Medical Compliance

MARCH 6, 2025

This training equips healthcare professionals with the skills and knowledge needed to enhance accountability, improve patient safety, and foster a positive work culture. Importance of Documentation in Healthcare Providers must document patient encounters accurately, fully, and on time.

Documentation/Coding 52

Documentation/Coding Patient Safety Leadership Outcomes 52

American Medical Compliance

AUGUST 7, 2024

Patient safety is a critical concern, with the World Health Organization (WHO) estimating that 1 in 10 patients is harmed while receiving healthcare. Compliance with healthcare regulations is crucial not only for avoiding legal repercussions but also for ensuring high standards of patient care and safety.

Hazardous Materials 105

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 105

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

EMDocs

APRIL 18, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. The admitting nurse documents an “OTJ injury” with a chief complaint of “My boss made me come.” To opt in to the free subscriber list, click here. Stories of med mal lawsuits can save lives.

Patient Safety 105

Patient Safety Hospitals Documentation/Coding EMS 105

EMDocs

OCTOBER 10, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. Exam is normal except for tenderness as documented in the diagram. She never had a documented abdominal exam. I just failed to document it. Stories of med mal lawsuits can save lives.

Documentation/Coding 97

Documentation/Coding Hospitals Sepsis Infectious Diseases 97

AENJ: Current Issue

SEPTEMBER 30, 2023

Pressure injuries (PIs) are an important quality and patient safety metric for health care organizations. A team at a Level 1 trauma center recognized the need for ED-friendly documentation and a validated ED skin risk assessment instrument. PI monitoring and treatment are often overlooked in the emergency department (ED).

Emergency Department 74

Emergency Department Patient Safety Documentation/Coding Research 74

EMDocs

JANUARY 25, 2024

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. The patient’s last INR should be documented, and one obtained if not recent. For patients on warfarin, documenting a reason for not checking an INR is a worthwhile practice.

Poisoning 98

Poisoning Documentation/Coding Patient Safety Hospitals 98

American Medical Compliance

JULY 2, 2024

Instances of Unprofessional Behavior Instances of unprofessional conduct in healthcare can undermine patient safety, cause distrust, and negatively impact team dynamics. Document observations consistently to identify patterns and trends over time. To become certified, please visit us at: American Medical Compliance (AMC).

Patient Safety 97

Patient Safety Documentation/Coding Outcomes Wellness 97

American Medical Compliance

FEBRUARY 9, 2024

They conduct internal audits and reviews to ensure adherence to regulations and recommend corrective actions when necessary. Reporting and Documentation Accurate record-keeping is a cornerstone of compliance. Compliance officers maintain detailed records of compliance activities, investigations, and corrective actions.

Operations 102

Operations Best Practices Patient Safety Documentation/Coding 102

Mind The Bleep

JULY 26, 2023

Good Medical Practice is the GMC’s core guidance document (a new version is out this year) and there are supporting documents covering important areas like consent , confidentiality , prescribing and treating children. Take care to document these discussions in the records. Most employers will have a chaperones policy too.

Documentation/Coding 52

Documentation/Coding Patient Safety Wellness Hospitals 52

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 52

Documentation/Coding Hospitals Patient Safety 52

ACEP Now

NOVEMBER 13, 2023

Managing and caring for aggressive patients may involve calling for security or physical and chemical restraints, but these interventions are temporary and have potential to further harm patients physically and mentally. A 2019 literature review summarized seven studies describing the creation and implementation of BERT teams.

Emergency Department 52

Emergency Department Documentation/Coding Psychiatric Best Practices 52

American Medical Compliance

DECEMBER 6, 2023

Elopement is defined by the VA National Center for Patient Safety (NCPS) as when a patient knows they are not allowed to leave but yet chooses to do so consciously. Finding out that a patient has “gone missing” is a terrifying experience for both clinicians and patients’ families.

Patient Safety 52

Patient Safety Documentation/Coding Hospitals 52

PDC Healthcare

OCTOBER 19, 2023

When a patient checks in to a hospital or a non-acute care facility, their personal and medical data needs to be recorded. Each patient has an EMR (Electronic Medical Record), which needs to be updated each time a patient needs care.

Hospitals 105

Hospitals Documentation/Coding Patient Safety 105

PDC Healthcare

MAY 1, 2023

Patient tracking during large-scale events is a challenge. Patients may be passed between first responders, ground transport, air transport, and then transferred from one facility to another. For routine calls with individual patients, it’s feasible to track who transported the patient and where they ended up.

Mass Casualty Incidents 98

Mass Casualty Incidents EMS Hospitals Documentation/Coding 98

PDC Healthcare

OCTOBER 19, 2023

When a patient checks in to a hospital or a non-acute care facility, their personal and medical data needs to be recorded. Each patient has an EMR (Electronic Medical Record), which needs to be updated each time a patient needs care.

Hospitals 98

Hospitals Documentation/Coding Patient Safety 98

PDC Healthcare

AUGUST 17, 2023

Key Takeaways from a Recent Pharmacy Survey PDC surveyed 6,400 Hospital Pharmacy Managers and Directors to get feedback on their priorities and challenges. Below we explore the results and key takeaways of the PDC survey, along with some helpful tips for pharmacy professionals.

Hospitals 98

Hospitals Patient Safety Documentation/Coding 98

ACEP Now

MARCH 13, 2024

Emergency departments (EDs) provide the essential service of evaluating patients with unscheduled, acute, undifferentiated, and decompensated conditions. Consequences of this are well documented and include delayed treatment, exposure to error, increased length of stay, and increased mortality. ED crowding impairs this mission.

Ethical Issues 52

Ethical Issues Emergency Department Operations Hospitals 52

EB Medicine

MAY 3, 2019

Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient.

Emergency Department 40

Emergency Department Psychiatric Documentation/Coding Outcomes 40

EB Medicine

JULY 8, 2019

Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Patients typically take vitamins postoperatively to prevent such complications. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: Nutritional deficiencies are also common complications. Metabolism.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

ACEP Now

AUGUST 1, 2023

The weighting must strongly be on patient safety and on expanding the opportunities for board certified emergency physicians. Every patient in a U.S. emergency department deserves access to an emergency physician no matter their zip code. We must always work against a balance. Three take home points for what I believe.

Emergency Department 98

Emergency Department EMS Critical Access Hospitals 98

The Skeptics' Guide to EM

MARCH 22, 2019

Most emergency physicians use some form of electronic medical records (EMRs) when seeing patients. The EMR tasks we undertake are expanding rapidly, far beyond simply documenting history and physical examination and every implementation slows us down. Research by Hill et al (1) demonstrated that an ED shift can have 4,000 clicks.

Emergency Department 52

Emergency Department Dislocations Documentation/Coding Research 52

American Medical Compliance

MARCH 19, 2025

The Mastering Healthcare Documentation Training teaches healthcare providers how to create comprehensive, accurate medical records that enhance patient care, ensure legal compliance, and drive quality improvement. The SOAP note is a way for healthcare workers to document in a structured and organized way.

Documentation/Coding 52

Documentation/Coding Outcomes Radiology Radiology 52

EMDocs

JANUARY 29, 2025

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. Takeaways: Documentation of rational MDM prevents lawsuits. Good doctors document good MDM. To opt in to the free subscriber list, click here. Stories of med mal lawsuits can save lives.

Documentation/Coding 82

Documentation/Coding Patient Safety Stroke EMS 82

EMDocs

FEBRUARY 21, 2025

The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. A nurse documents soft tissue tenderness in the back; the EPs note describes no tenderness and only decreased ROM of the back. To opt in to the free subscriber list, click here.

Documentation/Coding 89

Documentation/Coding Radiology Radiology Patient Safety 89

American Medical Compliance

MARCH 18, 2025

The course also covers best practices for medication storage, handling, and disposal, along with patient education strategies and methods to identify common medication errors. Understanding these fundamentals ensures patient safety, reduces medication-related risks, and enhances overall healthcare quality.

Administration 52

Administration Allergic Reactions Patient Safety Documentation/Coding 52

American Medical Compliance

FEBRUARY 21, 2025

This course will cover essential techniques for measuring vital signs, interpreting readings, recognizing early warning signs of patient decline, and ensuring proper documentation. Patient safety depends on the early detection of clinical deterioration, whether in the emergency department or on the hospital floor.

Patient Safety 52

Patient Safety Best Practices Emergency Department Documentation/Coding 52

American Medical Compliance

MARCH 14, 2025

By mastering these techniques, healthcare workers can reduce infection risks, protect patient safety, and maintain professional standards in home care. Providers can learn to minimize agitation, bag soiled linens at the point of use, and avoid sorting or pre-rinsing in patient areas.

Best Practices 52

Best Practices Patient Safety CPR Wellness 52