EMDocs

DECEMBER 4, 2023

Document a risk and benefit discussion with the patient regarding empiric anticoagulation, perhaps even including the HAS-BLED score in the documentation [10]. Thrombosis in the emergency department: use of a clinical diagnosis model to safely avoid the need for urgent radiological investigation. mg/kg for 24 hours.

Ultrasounds 95

Ultrasounds Documentation/Coding Wellness EMS 95

Emergency Medicine Journal

NOVEMBER 28, 2023

Method and Design The ED and radiology departments collaborated to develop an MRI direct to scan (DTS) pathway bypassing radiology discussions. All DTS scans had documented senior review at radiology request to ensure governance. There has been an increase in number of positive cases from 4.2% to 6.5%.

Radiology 40

Radiology Radiology Documentation/Coding Hospitals 40

RebelEM

SEPTEMBER 11, 2023

Outcomes: Primary: Percent change in management decisions after introducing the Radiology Department RUQ US. A change in clinical course resulting from a discrepancy between POCUS and radiology department imaging only occurred in 2% of patients (not 10%).

Ultrasounds 68

Ultrasounds Radiology Radiology Emergency Department 68

Mind The Bleep

APRIL 10, 2025

They can be fine tuned to respond to prompts and perform specific tasks such as finishing code, generating essays or textual responses to users. These are programmes that use deep learning and are trained using large (hence the name) sets of data to recognise and interpret human language or other types of complex data.

Documentation/Coding 52

Documentation/Coding Research Outcomes Administration 52

EMDocs

JUNE 22, 2023

I have been a part of many traumatic codes and resuscitations during my training, but I knew this one would probably be my most difficult one. The radiology tech has his hand on a weak femoral pulse. Should be here in 5 minutes.” reported one of the seasoned nurses. She was calm. My response: “Call everyone. Prepare everything.

Resuscitation 98

Resuscitation Ultrasounds Critical Access Radiology 98

EM Ottawa

OCTOBER 3, 2024

” However, when we combine POCUS images with clinical documentation, we are telling a story — and every good story has a beginning, middle, and end. Point-of-care ultrasound (POCUS) is often taught to answer binary questions, like, “Is there free fluid in the abdomen?”

Ultrasounds 55

Ultrasounds Documentation/Coding Radiology Radiology 55

Taming the SRU

SEPTEMBER 15, 2023

ultrasound grand rounds: bedside dvt studies - family presence in the ed/icu - r1 clinical knowledge: aicd - r3 small groups: difficult airway management Ultrasound grand rounds: DVT studies WITH Dr. minges Why should we perform bedside DVT studies in the ED? ETT onto a fiberoptic scope.

CPR 91

CPR Burns Airway Management Wellness 91

Sensible Medicine

SEPTEMBER 13, 2024

She presents with a folder of records and codes for outside EMRs. It is when you diagnose amyloidosis as the cause of a peripheral neuropathy, or find that the cause of a patient’s anxiety is hyponatremia, caused by SIADH, caused by a radiologically undetectable lung cancer. Sensible Medicine is a reader-supported publication.

Psychiatric 71

Psychiatric Radiology Radiology Documentation/Coding 71

Don't Forget the Bubbles

JANUARY 22, 2024

Clinical and radiological findings supported the diagnosis of pneumonia. A QIP performed in a paediatric intensive care unit aimed to reduce unnecessary LFT requests by implementing a blood test request form and a table of common investigations to facilitate and document discussion between the nursing and medical teams.

Emergency Department 90

Emergency Department Best Practices Radiology Radiology 90

Cook County EM Blog

MARCH 28, 2023

Surgery was completed approximately one month after presentation with improvement in vision to 20/80 at last documented ophthalmology follow up appointment. Ectopia Lentis: Radiology Reference Article.” OMFS was consulted for multiple facial fractures for which patient was set up to follow up in clinic. Cureus , Cureus, 24 Apr.

Dislocations 52

Dislocations Ultrasounds Fractures Radiology 52

Mind The Bleep

FEBRUARY 29, 2024

It is worth looking through previous documentation to see whether the patient’s team or senior intensivists have set any individual cardiovascular targets. Secretion burden and weak cough are common reasons for failed extubations, so this is a vital piece of information to guide clinical decisions.

Documentation/Coding 52

Documentation/Coding Hospitals Wellness Best Practices 52

Dr. Smith's ECG Blog

JUNE 27, 2021

A chest X-ray was obtained: This was read by radiology as "Bilateral lower lobe interstitial opacities. We should not have been fooled by the radiology reading of "pneumonia". This was not recognized. The patient was started on a nitro drip. The initial troponin I returned at 0.67 ng/mL (URL = 0.030 ng/mL).

EKG/ECG 40

EKG/ECG Radiology Radiology Ultrasounds 40

EMDocs

SEPTEMBER 26, 2024

Chuck Pilcher, MD, FACEP Editor, Medical Malpractice Insights Editor, Med Mal Insights Radiology over-reads – Who’s responsible? Patient not informed of enlarged heart, dies 3 weeks post ED visit Miscommunicated radiology findings are a hot topic. This patient’s history was either poorly taken or poorly documented.

Radiology 97

Radiology Radiology EKG/ECG Documentation/Coding 97

Mind The Bleep

FEBRUARY 2, 2025

Don’t panic: If you are the only available person and dont know the patient, document the information in the notes and let your senior know. Again, document the call clearly, discuss with your senior and implement further investigations/treatment as appropriate. link] Written by Emma Chrisholm ST1 Radiology

Radiology 98

Radiology Radiology Documentation/Coding Hospitals 98

EB Medicine

JULY 8, 2019

Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings. J Gastrointest Surg.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

EMDocs

NOVEMBER 16, 2024

Posterior – Shortened, adducted, internally rotated 5,6 Anterior – Shortened, abducted, externally rotated 5,6 As with all dislocations, perform and document distal neurovascular exam before and after management. 8 Perform and document distal neurovascular exam. 5 CT if concern for occult fracture.

EMS 97

EMS Dislocations Fractures Operations 97

EMDocs

FEBRUARY 12, 2025

13,16 In cases of radiological or nuclear incidents, follow referenced contamination and exposure protocols, including promptly consulting the radiation safety officer, wearing protective equipment, initiating decontamination measures and evaluating for acute radiation syndrome if indicated. J Appl Clin Med Phys. 2022;23(3):e13526.

Best Practices 56

Best Practices Documentation/Coding Radiology Radiology 56

EM Literature of Note

OCTOBER 9, 2024

Does this patient require radiologic investigations? The clinician reviewers – one resident physician and one attending physician – did not much agree (73-83% agreement) on admission, radiology, and antibiotic determinations. Specifically, the LLM – here GPT-3.5T and GPT-4T – is asked: Should this patient be admitted to the hospital?

Radiology 86

Radiology Radiology Emergency Department Documentation/Coding 86

Don't Forget the Bubbles

DECEMBER 2, 2024

This study relied on coding, and if the patient had not been coded as asthma, for example, and coded as pneumonia instead, these patients would not have been included in the study set. This highlights the need for departments to ensure timely radiology reports and continuous education of HCPs. and 16.7% , respectively.

Documentation/Coding 98

Documentation/Coding Pediatrics Emergency Department Fractures 98

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. If you take a history or examine a body part, document it. Temp is 98.7 and pulse 121.

Documentation/Coding 97

Documentation/Coding Hospitals Sepsis Infectious Diseases 97

The Trauma Pro

MAY 10, 2024

This fills in the code on the second tab which will be added to TraumaBase. If you use a different registry, contact your vendor for assistance. The spreadsheets consist of three tabs/pages. On the first, enter the specific field names from your TraumaBase implementation.

Blood Transfusions 113

Blood Transfusions Radiology Radiology Documentation/Coding 113

Northwestern EM Blog

MAY 16, 2022

vs. It is worth mentioning that this study was a multicenter study based in the US with representation from ED, Radiology, and Urology. Third, for those with proper training, and with some exceptions (see the systematic review paper for case vignettes that highlight these), POCUS is non-inferior to radiology-performed US.

Ultrasounds 52

Ultrasounds Radiology Radiology Outcomes 52

Don't Forget the Bubbles

MARCH 11, 2024

Craniosynostosis, The Radiology Assistant. The Radiology Assistant: Craniosynostosis Accessed 10.01.2024 Mawji, A., Recommendations for sudden infant death syndrome prevention: a discussion document. Prevalence, risk factors, and natural history of positional plagiocephaly: a systematic review. Vollman, A. Hatfield, J.,

Radiology 59

Radiology Radiology Pediatrics Documentation/Coding 59

Pediatric Emergency Playbook

JUNE 1, 2017

The best documented cormorbidity is sickle cell disease, although other pro-thrombotic conditions also put the child at risk. Myocardial infarction in an adult resulting from coronary aneurysms previously documented in childhood after an acute episode of Kawasaki’s disease. 1986; 108(2):198-203. Pongratz G et al. European Heart J.

Pediatrics 52

Pediatrics EKG/ECG Wellness Seizures 52

EB Medicine

JUNE 6, 2019

CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Nachi: All valid points, but let’s dive in too some actual detail.

Ultrasounds 40

Ultrasounds Radiology Radiology Sepsis 40

RebelEM

OCTOBER 5, 2023

Pneumonia diagnosis supported by clinical and radiologic criteria. While patients received respiratory support, supportive care, and antibiotics at the discretion of the medical team, the specific interventions provided outside the study were not documented, potentially leading to co-intervention bias.

Research 94

Research Outcomes Administration Shock 94

Taming the SRU

MAY 30, 2023

Generally accepted (and some airlines spell it out) that they are assuming the liability even for you helping Documentation: To protect yourself (and the airline), will/should make documentation of what happened. Airline companies have been sued. Each airline generally has their own protocol.

OB/GYN 52

OB/GYN Ultrasounds Pediatrics Resuscitation 52

Advanced Emergency Nursing from AENJ

FEBRUARY 29, 2016

Rebuilding of EDs in proximity to Radiology, Blood Bank, OR, and ICU, becoming organic to the hospital. EMS in America: The Foundation Documents. Milestones of Modern Progress in Emergency Care: WWII and Korean War military medical experience and progress. 1950s & 1960s Resuscitation Research. Touchstone, Mike. Sakran, J.

Emergency Nursing 40

Emergency Nursing EMS Resuscitation Military 40

EMDocs

JULY 3, 2023

This neurological evaluation should include assessment and documentation of the GCS, the presence of any neurologic deficits, and an NIHSS. 10 Additionally, discussion with radiology and neurology is advisable prior to obtaining an MRI, as data is not available to guide the specific timing of the test following symptom onset.

Seizures 98

Seizures Stroke Outcomes EMS 98

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

EB Medicine

JANUARY 2, 2019

Jeff: All patients with a positive pregnancy test and vaginal bleeding should receive an ultrasound performed by either an emergency physician or by radiology. For a completed abortion, you would expect a closed OS with no IUP on ultrasound with a previously documented IUP.

Ultrasounds 40

Ultrasounds Radiology Radiology Infectious Diseases 40

ACEP Now

FEBRUARY 19, 2025

As mentioned, AI has tremendous potential for automating non-teaming tasks such as documentation and data retrieval, and for managing ED workflow processes. AI emergency radiology tools can lead to immediate results for high-acuity patients, reducing delay in initiating treatments for acute patients. Artif Intell Med. 2020;102:101762.

Teamwork 51

Teamwork Clinical Decision Support Systems Administration Radiology 51

EMDocs

FEBRUARY 21, 2025

A nurse documents soft tissue tenderness in the back; the EPs note describes no tenderness and only decreased ROM of the back. The radiology report even advised If this study fails to adequately explain patients symptoms, additional imaging may be indicated. On arrival she has 9/10 right lower lumbar pain. A UA is normal with no RBCs.

Documentation/Coding 88

Documentation/Coding Radiology Radiology Patient Safety 88

Don't Forget the Bubbles

AUGUST 10, 2023

Descriptive Terms When describing injuries of the hand for documentation or referral purposes it is important to know the terminology that is widely in use in order to convey an accurate description to others. Hand dominance, mechanism of injury and vascular, neurological, and musculoskeletal status should all be evaluated and documented.

Fractures 52

Fractures Soft Tissue Injuries Emergency Department Operations 52

Taming the SRU

JUNE 6, 2023

mg/kg of IBW Seek to match a patient's minute ventilation with TV and RR after intubation Intentionally match patient's intrinsic RR noted prior to intubation Note that healthy lungs can handle 8 mL/kg, based on IBW, if that is useful for compensation Secure your ETT Thomas Tube Holder is a new ETT holder on Air Care for ETT down to size 6.5

Documentation/Coding 65

Documentation/Coding Seizures Psychiatric Wellness 65