Mind The Bleep

FEBRUARY 2, 2025

Often one of the scariest things you can do as you will most likely be speaking to a more senior colleague in an unfamiliar speciality. However, as an F1, you may well know the patient best and therefore you may be best placed to refer the patient.

Radiology 96

Radiology Radiology Sepsis Documentation/Coding 96

PEMBlog

JUNE 14, 2023

Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. Pediatrics March 2023; 151 (3): e2022057383. 10.1542/peds.2022-057383 2022-057383 Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. West J Emerg Med. 2019 Jul 22;20(5):690-695. doi: 10.5811/westjem.2019.6.42422.

Psychiatric 98

Psychiatric Emergency Department Pediatrics Best Practices 98

EMDocs

JUNE 9, 2023

We’re defining “protocol” here as a written document that provides oversight from the medical director about how to assess and treat patients. Reassessment and Documentation After any type of restraint is instituted, careful assessment, re-assessment, and documentation is required. Was the documentation complete?

EMS 89

EMS Documentation/Coding Pediatrics Psychiatric 89

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

Total Medical ComplianceHIPAA

OCTOBER 15, 2022

If a patient emails a request for their records, it is considered sufficient documentation for the practice to provide those records once the practice confirms the email address belongs to the patient. For example, if the patient’s email is not on file, call to confirm the request and email address and document the call in the patient’s file.

Documentation/Coding 52

Documentation/Coding Administration Wellness 52

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

EMDocs

MAY 26, 2023

Restraints should not be applied indefinitely, and multiple reevaluations should be done to determine when it is safe to remove restraints.

Pediatrics 88

Pediatrics Psychiatric Emergency Department Documentation/Coding 88